Provider Demographics
NPI:1053800847
Name:EXTENDED NP CARE LLC
Entity type:Organization
Organization Name:EXTENDED NP CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HEENAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:937-544-4020
Mailing Address - Street 1:7854 SPLIT RAIL CT
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-7982
Mailing Address - Country:US
Mailing Address - Phone:513-204-2854
Mailing Address - Fax:937-544-4009
Practice Address - Street 1:225 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1099
Practice Address - Country:US
Practice Address - Phone:513-248-1270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1053364737OtherNPI INDIVIDUAL
OH2693778Medicaid