Healthcare Provider Details

I. General information

NPI: 1215663323
Provider Name (Legal Business Name): IAN KINNAIRD CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8877 MENTOR AVE
MENTOR OH
44060-6211
US

IV. Provider business mailing address

ONE GI CREDENTIALING DEPARTMENT PO BOX 381468
GERMANTOWN TN
38183-9500
US

V. Phone/Fax

Practice location:
  • Phone: 440-205-1225
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN.CNP.0031220
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0031220
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: