Basic Information
| Provider Information | |||||||||
| NPI: | 1760886378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERGRIFF | ||||||||
| FirstName: | HOLLY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593316466 | ||||||||
| FaxNumber: | 8593447930 | ||||||||
| Practice Location | |||||||||
| Address1: | 4900 HOUSTON RD | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410424824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593316466 | ||||||||
| FaxNumber: | 8593447930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2014 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN323882 | OH | N | Nursing Service Providers | Registered Nurse | 363LA2100X | COA 16736 NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | 3011717 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0113154 | 05 | OH | MEDICAID | 201270520 | 05 | IN | MEDICAID | 7100325410 | 05 | KY | MEDICAID |