Healthcare Provider Details

I. General information

NPI: 1063195436
Provider Name (Legal Business Name): NICOLE PRYOR LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 OLD ROSEBUD RD STE 230
LEXINGTON KY
40509-8003
US

IV. Provider business mailing address

111 RIVER RUN CT
GEORGETOWN KY
40324-8444
US

V. Phone/Fax

Practice location:
  • Phone: 859-263-8833
  • Fax:
Mailing address:
  • Phone: 859-904-3134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number104962
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: