Provider Demographics
NPI:1043591233
Name:DESANTIS, BRYN MICHELLE (CNP)
Entity type:Individual
Prefix:MRS
First Name:BRYN
Middle Name:MICHELLE
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:BRYN
Other - Middle Name:MICHELLE
Other - Last Name:TROGDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:3400 OLENTANGY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1523
Mailing Address - Country:US
Mailing Address - Phone:614-754-5500
Mailing Address - Fax:614-457-9519
Practice Address - Street 1:30701 CLEMENS RD # CRW10
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1074
Practice Address - Country:US
Practice Address - Phone:440-617-1212
Practice Address - Fax:440-617-1213
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF0711138363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0056677Medicaid
OHH037340Medicare PIN