Healthcare Provider Details

I. General information

NPI: 1962867713
Provider Name (Legal Business Name): STAPLES HEALTH CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E MAIN ST
AUBURN KY
42206-5106
US

IV. Provider business mailing address

PO BOX 66
AUBURN KY
42206-0066
US

V. Phone/Fax

Practice location:
  • Phone: 270-438-3474
  • Fax:
Mailing address:
  • Phone: 270-438-3474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3005699
License Number StateKY

VIII. Authorized Official

Name: MRS. STACIA STAPLES
Title or Position: OWNER
Credential: APRN
Phone: 270-438-3474