1316029507 NPI number — MISS THERESA LYNN CLIFFORD F.N.P., A.P.R.N.

Table of content: (NPI 1992090443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316029507 NPI number — MISS THERESA LYNN CLIFFORD F.N.P., A.P.R.N.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLIFFORD
Provider First Name:
THERESA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
F.N.P., A.P.R.N.
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:
1316029507
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E LIBERTY ST STE 800
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:
40202-1428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-633-4622
Provider Business Mailing Address Fax Number:
502-633-6925

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 MACK WALTERS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40065-1738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-633-4622
Provider Business Practice Location Address Fax Number:
502-633-6925
Provider Enumeration Date:
10/19/2006

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:  3002154 , 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: 000000626807 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3722988000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100078250 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50024463 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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