Provider Demographics
NPI:1174596159
Name:RUNYON, NICHOLE MARIE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:MARIE
Last Name:RUNYON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 BURNT POND RD
Mailing Address - Street 2:
Mailing Address - City:OSTRANDER
Mailing Address - State:OH
Mailing Address - Zip Code:43061-9739
Mailing Address - Country:US
Mailing Address - Phone:614-216-7772
Mailing Address - Fax:
Practice Address - Street 1:1040 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6416
Practice Address - Country:US
Practice Address - Phone:740-383-8080
Practice Address - Fax:740-383-8084
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-12-15
Deactivation Date:2018-10-01
Deactivation Code:
Reactivation Date:2018-10-10
Provider Licenses
StateLicense IDTaxonomies
OHRN-308188163W00000X
OHAPRN.CNP.023698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0333675Medicaid