Healthcare Provider Details

I. General information

NPI: 1033871447
Provider Name (Legal Business Name): KING'S DAUGHTERS MEDICAL SPECIALTIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 10/13/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 29TH ST STE 201
ASHLAND KY
41101-1932
US

IV. Provider business mailing address

PO BOX 2379
ASHLAND KY
41105-2379
US

V. Phone/Fax

Practice location:
  • Phone: 606-420-0140
  • Fax: 606-420-0141
Mailing address:
  • Phone: 606-408-6200
  • Fax: 606-408-6612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: KRISTIE WHITLATCH
Title or Position: CEO
Credential:
Phone: 606-408-4401