Healthcare Provider Details

I. General information

NPI: 1558553560
Provider Name (Legal Business Name): ADVANCED CLINICAL DERMATOLOGY, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 HARRODSBURG RD SUITE C415
LEXINGTON KY
40504-3751
US

IV. Provider business mailing address

1401 HARRODSBURG RD SUITE C415
LEXINGTON KY
40504-3751
US

V. Phone/Fax

Practice location:
  • Phone: 859-288-5004
  • Fax: 859-288-5007
Mailing address:
  • Phone: 859-288-5004
  • Fax: 859-288-5007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number40054
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA602
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3688P
License Number StateKY

VIII. Authorized Official

Name: DR. LEIGH ANN CARTER
Title or Position: PRESIDENT/DERMATOLOGIST
Credential: M.D.
Phone: 859-288-5004