Provider Demographics
NPI:1194105692
Name:FONDRIEST, RAEANNE HUNTER (AG-ACNP)
Entity type:Individual
Prefix:MRS
First Name:RAEANNE
Middle Name:HUNTER
Last Name:FONDRIEST
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:MISS
Other - First Name:RAEANNE
Other - Middle Name:HUNTER
Other - Last Name:SCHAFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3535 PENTAGON BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1705
Mailing Address - Country:US
Mailing Address - Phone:937-702-4024
Mailing Address - Fax:937-702-4035
Practice Address - Street 1:3535 PENTAGON BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-1705
Practice Address - Country:US
Practice Address - Phone:937-702-4024
Practice Address - Fax:937-702-4035
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.17372-NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care