Healthcare Provider Details

I. General information

NPI: 1447809074
Provider Name (Legal Business Name): BETHANY KELLY LGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3470 BLAZER PKWY STE 200
LEXINGTON KY
40509-1887
US

IV. Provider business mailing address

1404 COPPER CREEK DR
LEXINGTON KY
40514-1276
US

V. Phone/Fax

Practice location:
  • Phone: 859-629-7117
  • Fax: 859-685-0161
Mailing address:
  • Phone: 859-537-4595
  • Fax: 859-685-0161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC159
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: