Healthcare Provider Details

I. General information

NPI: 1134224884
Provider Name (Legal Business Name): NANCY C KUPPERSMITH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S JACKSON ST 1ST FLOOR
LOUISVILLE KY
40202
US

IV. Provider business mailing address

501 E BROADWAY SUITE 120
LOUISVILLE KY
40202
US

V. Phone/Fax

Practice location:
  • Phone: 502-562-6503
  • Fax: 502-562-6504
Mailing address:
  • Phone: 502-562-6810
  • Fax: 502-562-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number0271
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: