Healthcare Provider Details

I. General information

NPI: 1689482580
Provider Name (Legal Business Name): STEPHANIE ELAINE MATTHEWS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 BATTERY PARK DR.
GLENDALE KY
42740
US

IV. Provider business mailing address

200 MICHAEL LN
BRANDENBURG KY
40108-8500
US

V. Phone/Fax

Practice location:
  • Phone: 270-668-7016
  • Fax:
Mailing address:
  • Phone: 270-668-7016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number1145253
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: