Provider Demographics
NPI:1619768579
Name:DAUTERMAN, LETICIA D
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:D
Last Name:DAUTERMAN
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 1:8000 N TOWNSHIP ROAD 63
Mailing Address - Street 2:
Mailing Address - City:RISINGSUN
Mailing Address - State:OH
Mailing Address - Zip Code:43457-9509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:439 W MARKET ST
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-2609
Practice Address - Country:US
Practice Address - Phone:419-455-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0039146363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health