Provider Demographics
NPI:1851009773
Name:BEAR, NICHOLE DIANE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:DIANE
Last Name:BEAR
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 1:340 E BRYAN ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1368
Mailing Address - Country:US
Mailing Address - Phone:419-799-7127
Mailing Address - Fax:
Practice Address - Street 1:340 E BRYAN ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1368
Practice Address - Country:US
Practice Address - Phone:419-799-7127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3651640376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH78662040Medicaid