Healthcare Provider Details

I. General information

NPI: 1720798606
Provider Name (Legal Business Name): LARRY TRENT CONLEY PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2022
Last Update Date: 12/01/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 N MAIN ST STE 240
HAZARD KY
41701-2503
US

IV. Provider business mailing address

2451 BIG BRANCH ROAD
HINDMAN KY
41822
US

V. Phone/Fax

Practice location:
  • Phone: 606-439-2662
  • Fax:
Mailing address:
  • Phone: 606-497-5828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3018666
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: