Healthcare Provider Details

I. General information

NPI: 1104275031
Provider Name (Legal Business Name): BETH DEYOUNG APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 07/10/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 EASTERN PKWY STE 2211
LOUISVILLE KY
40217-1444
US

IV. Provider business mailing address

1169 EASTERN PKWY STE 2211
LOUISVILLE KY
40217-1444
US

V. Phone/Fax

Practice location:
  • Phone: 502-635-2775
  • Fax: 502-371-0475
Mailing address:
  • Phone: 502-635-2775
  • Fax: 502-371-0475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number28163941A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3010700
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number1133702
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3010700
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: