Healthcare Provider Details

I. General information

NPI: 1114531803
Provider Name (Legal Business Name): KARALEE ANN MLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 SOUTH LIMESTONE K401
LEXINGTON KY
40536-0284
US

IV. Provider business mailing address

740 SOUTH LIMESTONE K401
LEXINGTON KY
40536-0284
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5533
  • Fax: 859-323-2412
Mailing address:
  • Phone: 859-323-5533
  • Fax: 859-323-2412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number3014780
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number3014780
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: