Healthcare Provider Details

I. General information

NPI: 1760870307
Provider Name (Legal Business Name): JENNIFER MAUPIN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 07/27/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 RICHMOND RD STE B
IRVINE KY
40336-7235
US

IV. Provider business mailing address

1561 RICHMOND RD STE B
IRVINE KY
40336-7235
US

V. Phone/Fax

Practice location:
  • Phone: 606-717-0177
  • Fax:
Mailing address:
  • Phone: 606-717-0177
  • Fax: 67-170-1566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCOA.16907-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3010614
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: