=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174233241
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COURTNEY NICOLE PURI AGACNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2022
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2150 W CENTRAL AVE
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43606-3834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-291-8701
-----------------------------------------------------
Fax | 419-479-3298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3788 TANNER MARIE DR
-----------------------------------------------------
City | ADRIAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49221-4417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-215-4096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.0032504
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------