Healthcare Provider Details

I. General information

NPI: 1417344136
Provider Name (Legal Business Name): RENE KUKKAMALLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 05/01/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S BROADWAY
LEXINGTON KY
40504-2701
US

IV. Provider business mailing address

1221 S BROADWAY
LEXINGTON KY
40504-2701
US

V. Phone/Fax

Practice location:
  • Phone: 859-258-4000
  • Fax: 859-258-6203
Mailing address:
  • Phone: 859-258-6200
  • Fax: 859-258-4000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number56420
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR6033
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: