Provider Demographics
NPI:1235138496
Name:SYBRANDY-NICELY, ELIZABETH G (DPM)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:G
Last Name:SYBRANDY-NICELY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:G
Other - Last Name:NICELY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:6200 PLEASANT AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4670
Mailing Address - Country:US
Mailing Address - Phone:937-293-8448
Mailing Address - Fax:937-617-4840
Practice Address - Street 1:1001 SHROYER RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45419-3635
Practice Address - Country:US
Practice Address - Phone:937-293-8448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2389213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0969831Medicaid
OH480020879OtherRAILROAD MEDICARE
OH0756791Medicare PIN
OH480020879OtherRAILROAD MEDICARE
OH0756794Medicare PIN
OH0969831Medicaid