Provider Demographics
NPI:1245202050
Name:DANNER, NICOLE J (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:DANNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5433 STATE ROUTE 113
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-9708
Mailing Address - Country:US
Mailing Address - Phone:419-483-2403
Mailing Address - Fax:419-483-8418
Practice Address - Street 1:5433 STATE ROUTE 113
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811-9708
Practice Address - Country:US
Practice Address - Phone:419-483-2403
Practice Address - Fax:429-483-8418
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340083172084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2576743Medicaid
OH11449810OtherCAQH
OHP00242190OtherRAILROAD MEDICARE
OH000000364458OtherANTHEM INS
OH7057683OtherAETNA INS
OH7057683OtherAETNA INS
OH4158081Medicare PIN