Provider Demographics
NPI:1134691470
Name:MIKLASEVICH, NICOLE ANDREA (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANDREA
Last Name:MIKLASEVICH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANDREA
Other - Last Name:KAMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:4315 CORINTH BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45410-3413
Mailing Address - Country:US
Mailing Address - Phone:419-356-0142
Mailing Address - Fax:
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:937-208-6173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CRNA.019794367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered