Provider Demographics
NPI:1912301284
Name:AYELE, ROMAN (PCA)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:AYELE
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6970 POLPIS RD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7169
Mailing Address - Country:US
Mailing Address - Phone:614-633-7253
Mailing Address - Fax:
Practice Address - Street 1:6970 POLPIS RD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-7169
Practice Address - Country:US
Practice Address - Phone:614-633-7253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2835089374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2835089Medicaid