Provider Demographics
NPI:1639489545
Name:MIDTLIEN, JENNIFER LYNN (CNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:MIDTLIEN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 PAXON DR
Mailing Address - Street 2:
Mailing Address - City:BELLBROOK
Mailing Address - State:OH
Mailing Address - Zip Code:45305-8948
Mailing Address - Country:US
Mailing Address - Phone:937-938-0136
Mailing Address - Fax:
Practice Address - Street 1:5300 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2381
Practice Address - Country:US
Practice Address - Phone:937-433-7536
Practice Address - Fax:937-433-9612
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN260615163W00000X
OH11935-NP364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9328817OtherAETNA
OH0058747Medicaid
OH421534506186OtherCARESOURCE OHIO
OH000000745200OtherANTHEM BCBS OH
OHP01005063OtherRR MEDICARE
OH9328817OtherAETNA