Healthcare Provider Details

I. General information

NPI: 1396375952
Provider Name (Legal Business Name): KEVIN THOMAS HARTLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 DIXIE HWY
FLORENCE KY
41042-2010
US

IV. Provider business mailing address

7000 DIXIE HWY
FLORENCE KY
41042-2010
US

V. Phone/Fax

Practice location:
  • Phone: 859-282-2024
  • Fax: 859-282-6747
Mailing address:
  • Phone: 859-282-2024
  • Fax: 859-282-6747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3014140
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3014140
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: