Provider Demographics
NPI:1669442455
Name:VANDLIK, SUSAN L (APRNCNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:VANDLIK
Suffix:
Gender:F
Credentials:APRNCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-6196
Mailing Address - Fax:
Practice Address - Street 1:300 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1280
Practice Address - Country:US
Practice Address - Phone:614-293-6196
Practice Address - Fax:614-366-0073
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.03438-NP363LA2200X
OHAPRN.CNP.03438363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2309120Medicaid
OHS92955Medicare UPIN
OH500010505Medicare ID - Type UnspecifiedRAILROAD
OHNP04484Medicare PIN