Healthcare Provider Details

I. General information

NPI: 1053305524
Provider Name (Legal Business Name): BARDSTOWN PRIMARY CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S 5TH ST
BARDSTOWN KY
40004-1142
US

IV. Provider business mailing address

201 S 5TH ST
BARDSTOWN KY
40004-1142
US

V. Phone/Fax

Practice location:
  • Phone: 502-348-7554
  • Fax: 502-337-6070
Mailing address:
  • Phone: 502-350-0050
  • Fax: 502-348-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARY JO NALLEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 502-348-7554