Healthcare Provider Details

I. General information

NPI: 1073616017
Provider Name (Legal Business Name): EDNA JEAN PENCE CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 WOODLAND DR
ELIZABETHTOWN KY
42701-2749
US

IV. Provider business mailing address

1115 WOODLAND DR
ELIZABETHTOWN KY
42701-2749
US

V. Phone/Fax

Practice location:
  • Phone: 270-769-5963
  • Fax: 270-769-9051
Mailing address:
  • Phone: 270-769-5963
  • Fax: 270-769-9051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number386M
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: