Basic Information
| Provider Information | |||||||||
| NPI: | 1730784059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SFILIGOJ | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | TRIHEALTH G LLC | ||||||||
| Address2: | 4685 FOREST AVE | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135696117 | ||||||||
| FaxNumber: | 5138534740 | ||||||||
| Practice Location | |||||||||
| Address1: | 10506 MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452424487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132328181 | ||||||||
| FaxNumber: | 5136242964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2020 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.0027168 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2565399 | 05 | OH | MEDICAID |