Healthcare Provider Details

I. General information

NPI: 1639882483
Provider Name (Legal Business Name): TRISTEN PAIGE DUNAGAN IECE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2022
Last Update Date: 12/26/2022
Certification Date: 12/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 BROADWAY ST
HORSE CAVE KY
42749-1205
US

IV. Provider business mailing address

308 WALTHALL ST
HORSE CAVE KY
42749-1137
US

V. Phone/Fax

Practice location:
  • Phone: 270-670-5357
  • Fax:
Mailing address:
  • Phone: 270-670-5290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number201189984
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: