Healthcare Provider Details

I. General information

NPI: 1447669478
Provider Name (Legal Business Name): ASHLEY C TANT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4402 CHURCHMAN AVE STE 409
LOUISVILLE KY
40215-1190
US

IV. Provider business mailing address

4402 CHURCHMAN AVE STE 409
LOUISVILLE KY
40215-1190
US

V. Phone/Fax

Practice location:
  • Phone: 502-368-9561
  • Fax: 502-882-1263
Mailing address:
  • Phone: 502-368-9561
  • Fax: 502-882-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number3008801
License Number StateKY

VIII. Authorized Official

Name: STACY L RALSTON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 502-368-9561