Basic Information
| Provider Information | |||||||||
| NPI: | 1790445245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONKLIN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | CPNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 CHILDRENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4126 N HOLLAND SYLVANIA RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436233537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195177658 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2021 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | APRN.CNP.0029621 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0344924 | 05 | OH | MEDICAID |