Healthcare Provider Details

I. General information

NPI: 1518948769
Provider Name (Legal Business Name): CARMELA FLETCHER-GREEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 VERSAILLES RD STE 120
LEXINGTON KY
40504-1795
US

IV. Provider business mailing address

1306 VERSAILLES RD STE 120
LEXINGTON KY
40504-1795
US

V. Phone/Fax

Practice location:
  • Phone: 859-259-2635
  • Fax:
Mailing address:
  • Phone: 859-259-2635
  • Fax: 592-547-8748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA304
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA304
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: