Basic Information
| Provider Information | |||||||||
| NPI: | 1700184306 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUER | ||||||||
| FirstName: | ANGIE | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410113313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596556100 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 7607 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410422644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596556100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2011 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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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 | 363LF0000X | COA 12215 NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 3007964 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100290260 | 05 | KY | MEDICAID | 0053056 | 05 | OH | MEDICAID | 201222370 | 05 | IN | MEDICAID |