1760631410 NPI number — MICKI L POCKER APRN

Table of content: MICKI L POCKER APRN (NPI 1760631410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760631410 NPI number — MICKI L POCKER APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POCKER
Provider First Name:
MICKI
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1760631410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-272-5395
Provider Business Mailing Address Fax Number:
502-272-5339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 S FLOYD ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-1837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-629-1515
Provider Business Practice Location Address Fax Number:
502-629-1545
Provider Enumeration Date:
09/17/2008

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: 363LW0102X , with the licence number:  3005612 , 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: 105635 . This is a "SIHO - LMVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000023036V . This is a "HUMANA - LMVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P00828506 . This is a "RAILROAD MEDICARE - LMVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100072010 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50024344 . This is a "PASSPORT - LMVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000735276 . This is a "ANTHEM - WOMEN'S SPECIALIST" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1408744 . This is a "CIGNA - LMVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3721649000 . This is a "PASSPORT ADVANTAGE - LMVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000620804 . This is a "ANTHEM - LMVA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200947930 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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