Healthcare Provider Details

I. General information

NPI: 1184145815
Provider Name (Legal Business Name): SMOKETOWN FAMILY WELLNESS CENTER CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 S HANCOCK ST APT B100
LOUISVILLE KY
40203-2449
US

IV. Provider business mailing address

760 S HANCOCK ST APT B100
LOUISVILLE KY
40203-2449
US

V. Phone/Fax

Practice location:
  • Phone: 502-242-7458
  • Fax:
Mailing address:
  • Phone: 502-242-7458
  • Fax: 502-219-3673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CHARLOTTE GAY STITES
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 502-242-7458