Healthcare Provider Details

I. General information

NPI: 1871092601
Provider Name (Legal Business Name): JILLIAN A CHAMPION RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILLIAN A PHELPS RN

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4423 BARDSTOWN RD
LOUISVILLE KY
40218-3235
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-749-7909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1141427
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3017762
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: