Healthcare Provider Details

I. General information

NPI: 1578531273
Provider Name (Legal Business Name): GRETCHEN KAY MALONE COF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 BROWNSBORO RD
LOUISVILLE KY
40207-2342
US

IV. Provider business mailing address

4850 BROWNSBORO RD
LOUISVILLE KY
40207-2342
US

V. Phone/Fax

Practice location:
  • Phone: 502-899-9177
  • Fax: 502-899-9178
Mailing address:
  • Phone: 502-899-9177
  • Fax: 502-899-9178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberCFO00523
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: