Provider Demographics
NPI:1003938432
Name:KAMSTRA, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KAMSTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 NEWPINE DR
Mailing Address - Street 2:
Mailing Address - City:CLEVES
Mailing Address - State:OH
Mailing Address - Zip Code:45002-2384
Mailing Address - Country:US
Mailing Address - Phone:513-941-2531
Mailing Address - Fax:
Practice Address - Street 1:5053 GLENWAY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-3903
Practice Address - Country:US
Practice Address - Phone:513-471-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-24700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist