Healthcare Provider Details

I. General information

NPI: 1942825658
Provider Name (Legal Business Name): WILLOW TREE PEDIATRICS OF LEXINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 03/07/2023
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2036 REGENCY RD STE 2
LEXINGTON KY
40503-2309
US

IV. Provider business mailing address

2036 REGENCY RD STE 2
LEXINGTON KY
40503-2309
US

V. Phone/Fax

Practice location:
  • Phone: 859-286-9046
  • Fax: 859-276-3726
Mailing address:
  • Phone: 859-286-9046
  • Fax: 859-276-3726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LORI DENISON
Title or Position: OWNER
Credential: APRN
Phone: 859-286-9046