Healthcare Provider Details

I. General information

NPI: 1053958793
Provider Name (Legal Business Name): ANDREA LILLIAN COLLINS RATLIFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4835 POPLAR LEVEL RD STE 110
LOUISVILLE KY
40213-2906
US

IV. Provider business mailing address

105 ANDERSON CT
RICHMOND KY
40475-3200
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax:
Mailing address:
  • Phone: 606-670-2165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: