Healthcare Provider Details

I. General information

NPI: 1275179020
Provider Name (Legal Business Name): GEORGETOWN PEDIATRICS, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1162 LEXINGTON RD
GEORGETOWN KY
40324-9330
US

IV. Provider business mailing address

1162 LEXINGTON RD
GEORGETOWN KY
40324-9330
US

V. Phone/Fax

Practice location:
  • Phone: 502-863-6426
  • Fax: 502-868-9724
Mailing address:
  • Phone: 502-863-6426
  • Fax: 502-868-9724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOHANNE GOODYKOONTZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 502-863-6426