Healthcare Provider Details

I. General information

NPI: 1811518541
Provider Name (Legal Business Name): AUTUMN ROSE BALLARD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AUTUMN ROSE KEENE

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MEDICAL HEIGHTS DR STE A
FRANKFORT KY
40601-4137
US

IV. Provider business mailing address

1221 S BROADWAY
LEXINGTON KY
40504-2701
US

V. Phone/Fax

Practice location:
  • Phone: 502-223-5758
  • Fax: 502-223-0047
Mailing address:
  • Phone: 859-258-6200
  • Fax: 859-258-6203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2724
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: