MEDICARE: MR. SAMUEL AGYENIM BOATENG CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APRN.CNP.025942	OH

General Provider Information

NPI Number	:	1033740824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SAMUEL AGYENIM BOATENG CNP

Provider Business Mailing Address
First Line	:	144 BRANDYWINE DR APT B
Second Line	:
City	:	WESTERVILLE
State	:	OH
Zip	:	43081-1379
Country	:	US
Telephone Number	:	614-806-8865
Fax Number	:

Provider Business Practice Location Address
First Line	:	HOLY HILLS HEALTHCARE SERVICES, LLC
Second Line	:	6760 TUSSING ROAD SUITE 104
City	:	REYNOLDSBURG
State	:	OH
Zip	:	43068-4136
Country	:	US
Telephone Number	:	614-626-6000
Fax Number	:	614-577-0807

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2020
Last Update Date	:	01/30/2020

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