Provider Demographics
NPI:1043592207
Name:TYCHONIEVICH, KIRSTEN MARIE (APRN-CNP)
Entity Type:Individual
Prefix:MS
First Name:KIRSTEN
Middle Name:MARIE
Last Name:TYCHONIEVICH
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:MS
Other - First Name:KIRSTEN
Other - Middle Name:MARIE BAUMAN
Other - Last Name:HOUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-366-6675
Mailing Address - Fax:614-366-8166
Practice Address - Street 1:2050 KENNY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3502
Practice Address - Country:US
Practice Address - Phone:614-366-6675
Practice Address - Fax:614-366-8166
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.12653363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0161002Medicaid
OHH449280Medicare PIN