Provider Demographics
NPI:1639867542
Name:NIENABER, ELIJAH MICHAEL
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:MICHAEL
Last Name:NIENABER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3642 WALNUT PARK DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:KY
Mailing Address - Zip Code:41001-9502
Mailing Address - Country:US
Mailing Address - Phone:859-912-9347
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2059
Practice Address - Country:US
Practice Address - Phone:310-222-3897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program