Provider Demographics
NPI:1902415524
Name:KINNEY, NICOLE DENISE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DENISE
Last Name:KINNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 POTTER PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45207-1016
Mailing Address - Country:US
Mailing Address - Phone:513-225-9829
Mailing Address - Fax:
Practice Address - Street 1:3505 STACEY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45207-1617
Practice Address - Country:US
Practice Address - Phone:513-225-9829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH264825505Medicaid