Provider Demographics
NPI:1538637046
Name:ILIAS, AYISHA (FNP-C)
Entity Type:Individual
Prefix:
First Name:AYISHA
Middle Name:
Last Name:ILIAS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5051 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-8181
Mailing Address - Country:US
Mailing Address - Phone:844-677-2378
Mailing Address - Fax:855-827-9978
Practice Address - Street 1:2818 MACK RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5130
Practice Address - Country:US
Practice Address - Phone:513-900-0750
Practice Address - Fax:513-816-7631
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLE-00025724363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH338509Medicaid