1124461017 NPI number — MISS AMANDA CHRISTINA KELLEY HIS

Table of content: MISS AMANDA CHRISTINA KELLEY HIS (NPI 1124461017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124461017 NPI number — MISS AMANDA CHRISTINA KELLEY HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
AMANDA
Provider Middle Name:
CHRISTINA
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
HIS
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:
1124461017
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 HARRODSBURG RD
Provider Second Line Business Mailing Address:
C-212
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40504-3751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-276-4327
Provider Business Mailing Address Fax Number:
859-309-3010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 HARRODSBURG RD
Provider Second Line Business Practice Location Address:
C-212
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40504-3751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-276-4327
Provider Business Practice Location Address Fax Number:
859-309-3010
Provider Enumeration Date:
04/10/2013

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: 237700000X , with the licence number:  1048 , 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)





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