Provider Demographics
NPI:1518909415
Name:KOSTUIK NEIDHARD, PAULA NICOLE (CNP)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:NICOLE
Last Name:KOSTUIK NEIDHARD
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 1:10506A MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-4402
Mailing Address - Country:US
Mailing Address - Phone:513-853-1300
Mailing Address - Fax:513-451-4118
Practice Address - Street 1:10506A MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4402
Practice Address - Country:US
Practice Address - Phone:513-853-1300
Practice Address - Fax:513-451-4118
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR152392363L00000X
OHCOA.18800-NP363LA2100X
OHAPRN.CNP.18800363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402732900Medicaid
MDG010 /OtherBLUECHOICE
MDKDA7 /OtherBC / BS OF MD
MDKDA7 /OtherBC / BS OF MD
165L / N320Medicare ID - Type Unspecified