Healthcare Provider Details

I. General information

NPI: 1548471741
Provider Name (Legal Business Name): MARY SUSAN DEARMOND CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2007
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 KRESGE WAY STE 200
LOUISVILLE KY
40207-4640
US

IV. Provider business mailing address

1206 MEADOWRIDGE TRL
GOSHEN KY
40026-9517
US

V. Phone/Fax

Practice location:
  • Phone: 502-895-1995
  • Fax: 502-895-6479
Mailing address:
  • Phone: 502-228-3175
  • Fax: 502-228-3175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number1039846
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: