=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700475373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KWADWO BOSOMPRAH NKANSA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2021
-----------------------------------------------------
Last Update Date | 02/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3122 AMBARWENT RD
-----------------------------------------------------
City | REYNOLDSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43068-7055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-537-7678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3122 AMBARWENT RD
-----------------------------------------------------
City | REYNOLDSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43068-7055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-537-7678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 138522
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------