Healthcare Provider Details

I. General information

NPI: 1972656379
Provider Name (Legal Business Name): SUSAN ASHLEY SHIVELY CRNFA, MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 LEBANON AVE
CAMPBELLSVILLE KY
42718-1809
US

IV. Provider business mailing address

803 LEBANON AVE
CAMPBELLSVILLE KY
42718-1809
US

V. Phone/Fax

Practice location:
  • Phone: 270-465-2521
  • Fax:
Mailing address:
  • Phone: 270-465-2521
  • Fax: 270-789-1756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3004973
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: