MEDICARE: EXTENDED NP CARE LLC

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	363L00000X	Nurse Practitioner		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1053364737	OTHER	OH	NPI INDIVIDUAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053800847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTENDED NP CARE LLC

Provider Business Mailing Address
First Line	:	7854 SPLIT RAIL CT
Second Line	:
City	:	MASON
State	:	OH
Zip	:	45040-7982
Country	:	US
Telephone Number	:	513-204-2854
Fax Number	:	937-544-4009

Provider Business Practice Location Address
First Line	:	225 CLEVELAND AVE
Second Line	:
City	:	MILFORD
State	:	OH
Zip	:	45150-1099
Country	:	US
Telephone Number	:	513-248-1270
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTIN ELIZABETH HEENAN
Credential	:	NP
Telephone Number	:	937-544-4020

Provider Enumeration Date	:	05/07/2018
Last Update Date	:	05/07/2018

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Directions to “EXTENDED NP CARE LLC ” Practice Location

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