Provider Demographics
NPI:1134997257
Name:DOUGLAS, RODELISA (CNP)
Entity type:Individual
Prefix:
First Name:RODELISA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3549 ALBERTA ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-1401
Mailing Address - Country:US
Mailing Address - Phone:614-381-4150
Mailing Address - Fax:
Practice Address - Street 1:1585 GEORGESVILLE SQUARE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-3777
Practice Address - Country:US
Practice Address - Phone:614-335-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0035121363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily