Healthcare Provider Details

I. General information

NPI: 1760746150
Provider Name (Legal Business Name): JESSICA LEIGH LANGE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N EAGLE CREEK DR STE 102
LEXINGTON KY
40509-1827
US

IV. Provider business mailing address

120 N EAGLE CREEK DR STE 102
LEXINGTON KY
40509-1827
US

V. Phone/Fax

Practice location:
  • Phone: 859-629-7140
  • Fax: 859-629-7137
Mailing address:
  • Phone: 859-629-7140
  • Fax: 859-629-7137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberT-2561
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number50404
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: