1396939484 NPI number — TEENA L TRENT PA

Table of content: TEENA L TRENT PA (NPI 1396939484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396939484 NPI number — TEENA L TRENT PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRENT
Provider First Name:
TEENA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396939484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 950202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40295-0202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1740 NICHOLASVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40503-1431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-260-6348
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA523 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 118070 . This is a "NNIKY - SIHO" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 95005658 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000675680 . This is a "NNIKY - ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 0000521554 . This is a "NNIKY - HUMANA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50034583 . This is a "PASSPORT - NNIKY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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