Provider Demographics
NPI:1356425565
Name:NISWONGER, JANE (CFNP)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:NISWONGER
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:300 E 8TH ST
Practice Address - Street 2:SUITE 120
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3379
Practice Address - Country:US
Practice Address - Phone:740-374-4273
Practice Address - Fax:740-376-5098
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.07456.NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2465836Medicaid
WV3810011076Medicaid
WV3810011076Medicaid
OH2465836Medicaid
OHP00954612OtherRRMCR
OHP00954612OtherRRMCR
OH000000562323OtherANTHEM
OH86911Medicare PIN