Provider Demographics
NPI:1710257167
Name:YOUNG, WAVA C (FNP-BC)
Entity Type:Individual
Prefix:
First Name:WAVA
Middle Name:C
Last Name:YOUNG
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2379
Mailing Address - Country:US
Mailing Address - Phone:937-651-6820
Mailing Address - Fax:937-651-6822
Practice Address - Street 1:1134 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311
Practice Address - Country:US
Practice Address - Phone:937-651-6820
Practice Address - Fax:937-651-6822
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.251868-COA1163W00000X
OHCOA.12987-NP363L00000X
OHAPRN.CNP.12987363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0061533Medicaid