Healthcare Provider Details

I. General information

NPI: 1972170181
Provider Name (Legal Business Name): LYDIA NICOLE PACK GC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST WHITNEY HENDRICKSON BLDG STE 134
LEXINGTON KY
40536-4322
US

IV. Provider business mailing address

800 ROSE ST
LEXINGTON KY
40536-7001
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-2650
  • Fax: 859-323-0702
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC563
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: