1457523623 NPI number — TRENNA LORETTA VANDERGRIFT APRN

Table of content: TRENNA LORETTA VANDERGRIFT APRN (NPI 1457523623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457523623 NPI number — TRENNA LORETTA VANDERGRIFT APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERGRIFT
Provider First Name:
TRENNA
Provider Middle Name:
LORETTA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KREILEIN
Provider Other First Name:
TRENNA
Provider Other Middle Name:
LORETTA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457523623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2308 MULUNDY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40511-8662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-351-7342
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 NEWTOWN PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40508-1113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-288-2483
Provider Business Practice Location Address Fax Number:
859-288-2469
Provider Enumeration Date:
03/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  3005515 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100132180 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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