Basic Information
| Provider Information | |||||||||
| NPI: | 1053800847 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXTENDED NP CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7854 SPLIT RAIL CT | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450407982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132042854 | ||||||||
| FaxNumber: | 9375444009 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451501099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132481270 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2018 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | HEENAN | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
| AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9375444020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1053364737 | 01 | OH | NPI INDIVIDUAL | OTHER | 2693778 | 05 | OH | MEDICAID |