Healthcare Provider Details

I. General information

NPI: 1104550862
Provider Name (Legal Business Name): JENAE KOTTER MSN, FNP-C, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S 4TH ST
LOUISVILLE KY
40203-3205
US

IV. Provider business mailing address

901 S 4TH ST
LOUISVILLE KY
40203-3205
US

V. Phone/Fax

Practice location:
  • Phone: 502-585-9911
  • Fax:
Mailing address:
  • Phone: 502-585-9911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3017863
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3017863
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: