=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548690233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUNAMIS AUXANO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2013
-----------------------------------------------------
Last Update Date | 11/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 W MAIN ST
-----------------------------------------------------
City | LOUDONVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44842-1247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-994-0212
-----------------------------------------------------
Fax | 419-994-0215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 W MAIN ST
-----------------------------------------------------
City | LOUDONVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44842-1247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-994-0212
-----------------------------------------------------
Fax | 419-994-0215
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED NURSE PRACTITIONER
-----------------------------------------------------
Name | DANIELE P MARSH
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 419-994-0212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11616
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------