Provider Demographics
NPI:1366092785
Name:RENICKER, KENNLY M (LPN)
Entity type:Individual
Prefix:
First Name:KENNLY
Middle Name:M
Last Name:RENICKER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 ALLERTON ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-4501
Mailing Address - Country:US
Mailing Address - Phone:740-319-9073
Mailing Address - Fax:
Practice Address - Street 1:709 ALLERTON ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4501
Practice Address - Country:US
Practice Address - Phone:740-319-9073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171650164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse