Healthcare Provider Details

I. General information

NPI: 1912565474
Provider Name (Legal Business Name): MEAGAN KOMONDOREAS CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE STE 201
LEXINGTON KY
40536-3079
US

IV. Provider business mailing address

800 ROSE ST # MS 475
LEXINGTON KY
40536-3078
US

V. Phone/Fax

Practice location:
  • Phone: 859-218-2522
  • Fax: 859-323-3918
Mailing address:
  • Phone: 859-323-5625
  • Fax: 859-323-5289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP139810
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number3016418
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number3016418
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: