Provider Demographics
NPI:1477253292
Name:WEISBRODT, NICOLE ELIZABETH
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:WEISBRODT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:MANNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5315 KERNAN RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45142-9514
Mailing Address - Country:US
Mailing Address - Phone:937-205-8580
Mailing Address - Fax:
Practice Address - Street 1:5315 KERNAN RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:OH
Practice Address - Zip Code:45142-9514
Practice Address - Country:US
Practice Address - Phone:937-205-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH402124981218376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide