Provider Demographics
NPI:1861914442
Name:BUSH, KATIE M (MSN, CNP)
Entity type:Individual
Prefix:MS
First Name:KATIE
Middle Name:M
Last Name:BUSH
Suffix:
Gender:F
Credentials:MSN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 NAVARRE AVE
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3207
Mailing Address - Country:US
Mailing Address - Phone:419-696-8882
Mailing Address - Fax:419-696-8819
Practice Address - Street 1:2600 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3207
Practice Address - Country:US
Practice Address - Phone:419-696-8882
Practice Address - Fax:419-696-8819
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024191966363LP0808X
OHAPRN.CNP.021071363LF0000X, 363LP0808X
KY4030094363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0248238Medicaid