1164935599 NPI number — KENYATTA DENISE ANDERSON FNP-C

Table of content: KENYATTA DENISE ANDERSON FNP-C (NPI 1164935599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164935599 NPI number — KENYATTA DENISE ANDERSON FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
KENYATTA
Provider Middle Name:
DENISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VANCE-ANDERSON
Provider Other First Name:
KENYATTA
Provider Other Middle Name:
DEVISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164935599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5357 BROADVIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44134-1607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-263-6120
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12914 BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARFIELD HEIGHTS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44125-1859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-848-9123
Provider Business Practice Location Address Fax Number:
216-848-9123
Provider Enumeration Date:
11/07/2017

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:  024369 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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