Provider Demographics
NPI:1104376219
Name:POTHAST, NICOLE MARIE (MSN, CNM)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:POTHAST
Suffix:
Gender:F
Credentials:MSN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1690
Mailing Address - Country:US
Mailing Address - Phone:419-636-5414
Mailing Address - Fax:419-636-3100
Practice Address - Street 1:433 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1690
Practice Address - Country:US
Practice Address - Phone:419-636-1131
Practice Address - Fax:419-636-3100
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006654367A00000X
OH019332367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife