Provider Demographics
NPI:1679860159
Name:THEADO, ELIZABETH A (RN, NNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:THEADO
Suffix:
Gender:F
Credentials:RN, NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1678 DOLLIVOR DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1106
Mailing Address - Country:US
Mailing Address - Phone:614-353-3715
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-4654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH316344163WN0002X
OHAPRN.CNP.12547363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0082623Medicaid