Provider Demographics
NPI:1275953408
Name:SAMPLE, NANCY S (CNS)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:S
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 FRANTZ RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4144
Mailing Address - Country:US
Mailing Address - Phone:614-544-6356
Mailing Address - Fax:
Practice Address - Street 1:3705 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3467
Practice Address - Country:US
Practice Address - Phone:614-262-6772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.186505163W00000X
OHCOA.16623-NS364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0112533Medicaid
OH0112533Medicaid