Healthcare Provider Details

I. General information

NPI: 1861993263
Provider Name (Legal Business Name): HEALTHCARE FOR KIDS & TEENS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 MILLER PIKE
LEBANON KY
40033-9248
US

IV. Provider business mailing address

54 MILLER PIKE
LEBANON KY
40033-9248
US

V. Phone/Fax

Practice location:
  • Phone: 270-692-9015
  • Fax: 270-692-9008
Mailing address:
  • Phone: 270-692-9015
  • Fax: 270-692-9008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3004368
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number3004368
License Number StateKY

VIII. Authorized Official

Name: JENNIFER MULLINS
Title or Position: OWNER/PROVIDER
Credential: APRN
Phone: 270-692-9015