Healthcare Provider Details

I. General information

NPI: 1255392973
Provider Name (Legal Business Name): CASSIE L LANDRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1792 ALYSHEBA WAY
LEXINGTON KY
40509-2288
US

IV. Provider business mailing address

1792 ALYSHEBA WAY
LEXINGTON KY
40509-2288
US

V. Phone/Fax

Practice location:
  • Phone: 859-293-6133
  • Fax:
Mailing address:
  • Phone: 859-293-6133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number004801
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: