Healthcare Provider Details

I. General information

NPI: 1457012205
Provider Name (Legal Business Name): WELLINGTON PROVIDER GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 WELLINGTON WAY STE 330
LEXINGTON KY
40503-1331
US

IV. Provider business mailing address

535 WELLINGTON WAY STE 330
LEXINGTON KY
40503-1331
US

V. Phone/Fax

Practice location:
  • Phone: 859-439-0399
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QG0250X
TaxonomyGenetics Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRITTANY DENNIS
Title or Position: BILLING/CREDENTIALING MANAGER
Credential:
Phone: 859-518-8817