Basic Information
| Provider Information | |||||||||
| NPI: | 1063951952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CREEDON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST FL 7 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197947700 | ||||||||
| FaxNumber: | 4197947715 | ||||||||
| Practice Location | |||||||||
| Address1: | 5705 MONCLOVA RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435371877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197947700 | ||||||||
| FaxNumber: | 4197947715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2017 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN.365677 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | APRN.CNP.020424 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | OH | LICENSE-APRN.CNP | OTHER | PENDING | 05 | OH | MEDICAID |