=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508511692
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL M. HODGE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2022
-----------------------------------------------------
Last Update Date | 06/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4850 SMITH RD STE 250
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45212-2733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-699-9090
-----------------------------------------------------
Fax | 513-258-2053
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6094 DAWSON DR
-----------------------------------------------------
City | LIBERTY TWP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45044-1254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-869-9322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.0030756
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------