1356809768 NPI number — STACEY C GREENWELL-OSBORNE

Table of content: STACEY C GREENWELL-OSBORNE (NPI 1356809768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356809768 NPI number — STACEY C GREENWELL-OSBORNE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENWELL-OSBORNE
Provider First Name:
STACEY
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1356809768
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 936
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40743-0936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
606-330-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4359 NEW SHEPHERDSVILLE RD UNIT 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARDSTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40004-8003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-350-1302
Provider Business Practice Location Address Fax Number:
502-350-1185
Provider Enumeration Date:
03/05/2019

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:  3013037 , 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)