Provider Demographics
NPI:1861200651
Name:DEPASS-SURGEON, NICKETTE DONNA MARIE (FNP)
Entity type:Individual
Prefix:
First Name:NICKETTE
Middle Name:DONNA MARIE
Last Name:DEPASS-SURGEON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6011 CLEVELAND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-2256
Mailing Address - Country:US
Mailing Address - Phone:614-966-1690
Mailing Address - Fax:614-368-0448
Practice Address - Street 1:6011 CLEVELAND AVE STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-2256
Practice Address - Country:US
Practice Address - Phone:614-966-1690
Practice Address - Fax:614-368-0448
Is Sole Proprietor?:No
Enumeration Date:2024-12-25
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CPN.0038251363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care