Provider Demographics
NPI:1255169546
Name:DETZEL, AMIE NICOLE
Entity type:Individual
Prefix:
First Name:AMIE
Middle Name:NICOLE
Last Name:DETZEL
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 1:4104 FLOWER AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45205-2086
Mailing Address - Country:US
Mailing Address - Phone:513-915-4999
Mailing Address - Fax:
Practice Address - Street 1:4104 FLOWER AVE APT 3
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45205-2086
Practice Address - Country:US
Practice Address - Phone:513-915-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.004866175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist