Healthcare Provider Details

I. General information

NPI: 1922269307
Provider Name (Legal Business Name): STEPHANIE K PRIDEMORE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE STE C300
LEXINGTON KY
40536-3706
US

IV. Provider business mailing address

1618 HARRODSBURG RD
LEXINGTON KY
40504-3706
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-5405
  • Fax: 859-323-5483
Mailing address:
  • Phone: 859-288-5004
  • Fax: 859-288-5007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberPA602
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA602
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA602
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA602
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: