Basic Information
| Provider Information | |||||||||
| NPI: | 1083697585 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZIDEK | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1240 RAVELLE CT | ||||||||
| Address2: | BELLBROOK | ||||||||
| City: | BELLBROOK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453058760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378487372 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3033 KETTERING BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372932133 | ||||||||
| FaxNumber: | 9372932161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 05/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP05623 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2305777 | 05 | OH | MEDICAID |