Provider Demographics
NPI:1801403381
Name:OLTORIK, MICHELLE ELISE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELISE
Last Name:OLTORIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9628 COOPER LN
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-7004
Mailing Address - Country:US
Mailing Address - Phone:513-314-9692
Mailing Address - Fax:
Practice Address - Street 1:9628 COOPER LN
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-7004
Practice Address - Country:US
Practice Address - Phone:513-314-9692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH31180303747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3118030Medicaid
OH0054353Medicaid