Provider Demographics
NPI:1922284660
Name:TENNANT, ANGELA (APRN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:TENNANT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:HAVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-301-2000
Mailing Address - Fax:859-426-4140
Practice Address - Street 1:1 MEDICAL VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-301-2000
Practice Address - Fax:859-426-4140
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003096363L00000X, 363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78003951Medicaid
OH0163925Medicaid
IN201359370Medicaid
KYP400029929Medicare PIN
KYK174451Medicare PIN
KYK174450Medicare PIN