Healthcare Provider Details

I. General information

NPI: 1831802438
Provider Name (Legal Business Name): RICKY EVERSOLE JR. APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DRIVE
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

P.O. BOX 636324
CINCINNATI OH
45263-6324
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2000
  • Fax: 859-301-6910
Mailing address:
  • Phone: 859-344-5555
  • Fax: 859-344-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71014878A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number3018133
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3018133
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: