Provider Demographics
NPI:1225410830
Name:KNOWLTON FAMILY PRACTICE
Entity Type:Organization
Organization Name:KNOWLTON FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LESLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOWLTON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:740-629-8528
Mailing Address - Street 1:1001 PIKE ST
Mailing Address - Street 2:7A
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-3515
Mailing Address - Country:US
Mailing Address - Phone:740-629-8528
Mailing Address - Fax:
Practice Address - Street 1:1001 PIKE ST
Practice Address - Street 2:7A
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3515
Practice Address - Country:US
Practice Address - Phone:740-629-8528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP08402261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2645310Medicaid
OH3810011090Medicaid
NP86891Medicare Oscar/Certification
OH3810011090Medicaid