Healthcare Provider Details

I. General information

NPI: 1790317048
Provider Name (Legal Business Name): ADRIANNE OTWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 LEXINGTON AVE
ASHLAND KY
41101-2843
US

IV. Provider business mailing address

PO BOX 2379
ASHLAND KY
41105-2379
US

V. Phone/Fax

Practice location:
  • Phone: 606-408-4000
  • Fax:
Mailing address:
  • Phone: 606-408-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAG01200156
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number3014433
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: