Healthcare Provider Details

I. General information

NPI: 1689418337
Provider Name (Legal Business Name): JEREMY TODD WHEATLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 BELINDA BLVD
DANVILLE KY
40422-3217
US

IV. Provider business mailing address

121 MAN O WAR DR
HARRODSBURG KY
40330-7507
US

V. Phone/Fax

Practice location:
  • Phone: 859-439-0340
  • Fax:
Mailing address:
  • Phone: 859-297-8394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: