Provider Demographics
NPI:1396375952
Name:HARTLEY, KEVIN THOMAS
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:THOMAS
Last Name:HARTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-0330
Mailing Address - Country:US
Mailing Address - Phone:513-454-7246
Mailing Address - Fax:513-438-0202
Practice Address - Street 1:111 VANDAMENT WAY
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-8311
Practice Address - Country:US
Practice Address - Phone:513-454-7246
Practice Address - Fax:513-438-0202
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014140363LF0000X
OHF10190856363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily