Provider Demographics
NPI:1184934655
Name:KENREICH, HOLLY A (CNP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:A
Last Name:KENREICH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:A
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:320 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1280
Mailing Address - Country:US
Mailing Address - Phone:614-293-8619
Mailing Address - Fax:614-293-6420
Practice Address - Street 1:300 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1280
Practice Address - Country:US
Practice Address - Phone:614-293-8619
Practice Address - Fax:614-293-6420
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.349162163W00000X
OHCOA.11710-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3107113Medicaid