MEDICARE: MALACHI GRUENHAGEN RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	393748	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	393748	OTHER	OH	RN LICENSE ISSUED BY OHIO BOARD OF NURSING

General Provider Information

NPI Number	:	1538947312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALACHI GRUENHAGEN RN

Provider Business Mailing Address
First Line	:	2658 VERA AVE APT 2
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45237-4577
Country	:	US
Telephone Number	:	513-388-7157
Fax Number	:

Provider Business Practice Location Address
First Line	:	4129 E GALBRAITH RD
Second Line	:
City	:	DEER PARK
State	:	OH
Zip	:	45236-2417
Country	:	US
Telephone Number	:	513-686-7809
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2023
Last Update Date	:	09/21/2023

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