1871758417 NPI number — MRS. LAURA ROSS MATHERLY ARNP

Table of content: MRS. LAURA ROSS MATHERLY ARNP (NPI 1871758417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871758417 NPI number — MRS. LAURA ROSS MATHERLY ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHERLY
Provider First Name:
LAURA
Provider Middle Name:
ROSS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1871758417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2019
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:
606-330-7818
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
Provider Second Line Business Practice Location Address:
SUITE 255
Provider Business Practice Location Address City Name:
BARDSTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40004-8000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-350-5800
Provider Business Practice Location Address Fax Number:
502-350-5820
Provider Enumeration Date:
07/23/2008

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: 363LF0000X , with the licence number:  5616P , 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: 7100100500 (KOHMG) , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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