Healthcare Provider Details

I. General information

NPI: 1356689079
Provider Name (Legal Business Name): BOURBON PHYSICIAN PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 09/24/2022
Certification Date: 09/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S BROADWAY ST
CARLISLE KY
40311-1150
US

IV. Provider business mailing address

107 S BROADWAY ST
CARLISLE KY
40311-1150
US

V. Phone/Fax

Practice location:
  • Phone: 859-289-4124
  • Fax: 859-289-4126
Mailing address:
  • Phone: 859-289-4124
  • Fax: 859-289-4126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateKY

VIII. Authorized Official

Name: MONICA BOWMAN
Title or Position: PRESIDENT
Credential:
Phone: 615-920-7000