Healthcare Provider Details

I. General information

NPI: 1649654880
Provider Name (Legal Business Name): JOYCE DENISE THACKER APRN-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

989 GOVERNORS LN STE 180
LEXINGTON KY
40513-1174
US

IV. Provider business mailing address

1260 MCCROSKEY DRIVE
MOUNT STERLING KY
40353
US

V. Phone/Fax

Practice location:
  • Phone: 859-274-2296
  • Fax:
Mailing address:
  • Phone: 859-274-2296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number3009100
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number3009100
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number3009100
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: