Healthcare Provider Details

I. General information

NPI: 1083538490
Provider Name (Legal Business Name): CREATIONZ BY PHOENIX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2366 ALLEN DR STE B
LEXINGTON KY
40505-1956
US

IV. Provider business mailing address

212 N 2ND ST STE 100
RICHMOND KY
40475-1408
US

V. Phone/Fax

Practice location:
  • Phone: 859-519-9336
  • Fax:
Mailing address:
  • Phone: 859-519-9336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State

VIII. Authorized Official

Name: MS. SHA'NAE LATISHA HAMMOND
Title or Position: OWNER
Credential: CNA
Phone: 859-519-9336