Healthcare Provider Details

I. General information

NPI: 1184934655
Provider Name (Legal Business Name): HOLLY A KENREICH CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY A WAGNER CNP

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W 10TH AVE
COLUMBUS OH
43210-1280
US

IV. Provider business mailing address

320 W 10TH AVE
COLUMBUS OH
43210-1280
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-8619
  • Fax: 614-293-6420
Mailing address:
  • Phone: 614-293-8619
  • Fax: 614-293-6420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.11710-NP
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.349162
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: