Healthcare Provider Details

I. General information

NPI: 1962598557
Provider Name (Legal Business Name): TINA L SNODGRASS APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 N MAIN ST STE 2
BEAVER DAM KY
42320-8955
US

IV. Provider business mailing address

1219 N MAIN ST STE 2
BEAVER DAM KY
42320-8955
US

V. Phone/Fax

Practice location:
  • Phone: 270-926-0707
  • Fax:
Mailing address:
  • Phone: 270-926-0707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3002620
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number3002620
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: