Provider Demographics
NPI:1457523623
Name:VANDERGRIFT, TRENNA LORETTA (APRN)
Entity Type:Individual
Prefix:
First Name:TRENNA
Middle Name:LORETTA
Last Name:VANDERGRIFT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TRENNA
Other - Middle Name:LORETTA
Other - Last Name:KREILEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:2308 MULUNDY WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-8662
Mailing Address - Country:US
Mailing Address - Phone:859-351-7342
Mailing Address - Fax:
Practice Address - Street 1:650 NEWTOWN PIKE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-1113
Practice Address - Country:US
Practice Address - Phone:859-288-2483
Practice Address - Fax:859-288-2469
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005515363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100132180Medicaid
KY7100132180Medicaid