Healthcare Provider Details

I. General information

NPI: 1124760657
Provider Name (Legal Business Name): DANA FAYE EMBERTON-TINIUS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 NATCHEZ TRACE AVE
BOWLING GREEN KY
42103-7995
US

IV. Provider business mailing address

225 NATCHEZ TRACE AVE
BOWLING GREEN KY
42103-7995
US

V. Phone/Fax

Practice location:
  • Phone: 270-783-3573
  • Fax: 270-783-4081
Mailing address:
  • Phone: 270-783-3573
  • Fax: 270-783-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3018235
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1054145
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: