Healthcare Provider Details

I. General information

NPI: 1598804973
Provider Name (Legal Business Name): CAROL ENNIS MARTIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 09/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

THE KENTUCKY CLINIC WING D J252 740 S. LIMESTONE
LEXINGTON KY
40536
US

IV. Provider business mailing address

740 S. LIMESTONE THE KENTUCKY CLINIC WING D - J252
LEXINGTON KY
40536-0284
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-2089
  • Fax: 859-218-7487
Mailing address:
  • Phone: 859-218-0362
  • Fax: 859-257-5013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number3002688
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: