Healthcare Provider Details

I. General information

NPI: 1003291360
Provider Name (Legal Business Name): JEANIE NICOLE DOOM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 W FAIRVIEW AVE
EDDYVILLE KY
42038-7386
US

IV. Provider business mailing address

1901 CAMPUS PL
LOUISVILLE KY
40299-2308
US

V. Phone/Fax

Practice location:
  • Phone: 270-388-5454
  • Fax: 270-388-5452
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3009544
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: