Provider Demographics
NPI:1225146558
Name:NIEDEREGGER, ELIZABETH BANKES (CNM)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BANKES
Last Name:NIEDEREGGER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:BANKES
Other - Last Name:NIEDEREGGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-585-5505
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-584-4800
Practice Address - Fax:513-584-0635
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN229708163WW0101X, 163WX0003X
OHCOA 05290 NM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH310832874029Medicaid
OH310832874Medicaid
OH000000379320OtherBLUE CROSS & BLUE SHIELD
OH11508741OtherCAQH NUMBER
OH292503Medicaid
OH2507764Medicaid
OH000000379320OtherBLUE CROSS & BLUE SHIELD
OH310832874Medicaid