Provider Demographics
NPI:1699433235
Name:CUSTARD, ADRIENNE
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:CUSTARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-1183
Mailing Address - Country:US
Mailing Address - Phone:614-276-2273
Mailing Address - Fax:
Practice Address - Street 1:199 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-1301
Practice Address - Country:US
Practice Address - Phone:161-427-6227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker