MEDICARE: MS. PAULA A BASE NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	3002822	KY

General Provider Information

NPI Number	:	1104921147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PAULA A BASE NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	12201 BLUEGRASS PKWY
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40299-2361
Country	:	US
Telephone Number	:	502-568-7364
Fax Number	:	502-568-7136

Provider Business Practice Location Address
First Line	:	2529 SIX MILE LN
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40220-2934
Country	:	US
Telephone Number	:	502-491-5560
Fax Number	:	502-491-0214

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	12/16/2015

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