Healthcare Provider Details

I. General information

NPI: 1083066591
Provider Name (Legal Business Name): ALLISON DREW DEZARN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 BLACK GOLD BLVD
HAZARD KY
41701-2620
US

IV. Provider business mailing address

279 E MAIN ST
HAZARD KY
41701-1973
US

V. Phone/Fax

Practice location:
  • Phone: 606-436-0711
  • Fax: 606-436-0519
Mailing address:
  • Phone: 606-487-9505
  • Fax: 606-436-0711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number3010409
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3010409
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: