1306204490 NPI number — MRS. EMILY TABOR JESSIE APRN

Table of content: MRS. EMILY TABOR JESSIE APRN (NPI 1306204490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306204490 NPI number — MRS. EMILY TABOR JESSIE APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JESSIE
Provider First Name:
EMILY
Provider Middle Name:
TABOR
Provider Name Prefix Text:
MRS.
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:
1306204490
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 N RACE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLASGOW
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42141-3454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-651-4444
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1084 VETERANS MEMORIAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42164-9602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-373-1232
Provider Business Practice Location Address Fax Number:
270-237-3139
Provider Enumeration Date:
02/03/2016

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: 363LF0000X , with the licence number:  3010029 , 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: 7100474280 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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