Healthcare Provider Details

I. General information

NPI: 1447702659
Provider Name (Legal Business Name): ANGELA EVERSOLE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 CUMBERLAND GAP PLZ
GRAY KY
40734-4536
US

IV. Provider business mailing address

2700 STANLEY GAULT PKWY STE 129
LOUISVILLE KY
40223-5176
US

V. Phone/Fax

Practice location:
  • Phone: 606-526-9005
  • Fax: 606-526-8607
Mailing address:
  • Phone: 502-253-4914
  • Fax: 502-489-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3010848
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: