MEDICARE: ELIZABETH ANN ISLAM NP-C

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	363LA2200X	Adult Health Nurse Practitioner	11775	OH
2	363L00000X	Nurse Practitioner	11775	OH

General Provider Information

NPI Number	:	1588970750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH ANN ISLAM NP-C

Provider Business Mailing Address
First Line	:	2830 VICTORY PKWY
Second Line	:	LL30
City	:	CINCINNATI
State	:	OH
Zip	:	45206-1785
Country	:	US
Telephone Number	:	513-245-3335
Fax Number	:	513-475-7259

Provider Business Practice Location Address
First Line	:	2123 AUBURN AVE
Second Line	:	SUITE 524
City	:	CINCINNATI
State	:	OH
Zip	:	45219-2906
Country	:	US
Telephone Number	:	513-929-0104
Fax Number	:	513-929-4369

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

Provider Enumeration Date	:	08/26/2010
Last Update Date	:	09/18/2012

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