Healthcare Provider Details

I. General information

NPI: 1073917472
Provider Name (Legal Business Name): TINA NICOLE CRUSE B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 NEWTOWN PIKE
LEXINGTON KY
40511-1275
US

IV. Provider business mailing address

1351 NEWTOWN PIKE
LEXINGTON KY
40511-1275
US

V. Phone/Fax

Practice location:
  • Phone: 859-271-9448
  • Fax: 859-272-6893
Mailing address:
  • Phone: 859-271-9448
  • Fax: 859-272-6893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: