MEDICARE: JULIE ELIZABETH DVERSDALL RN, CPNP

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	363LP0200X	Pediatric Nurse Practitioner	COA.09824-NP	OH

General Provider Information

NPI Number	:	1871645994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE ELIZABETH DVERSDALL RN, CPNP

Provider Business Mailing Address
First Line	:	2515 CLIFTON AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45219-1003
Country	:	US
Telephone Number	:	513-367-5888
Fax Number	:	513-367-1015

Provider Business Practice Location Address
First Line	:	2515 CLIFTON AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45219-1003
Country	:	US
Telephone Number	:	513-367-5888
Fax Number	:	513-367-1015

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	02/12/2015

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