Healthcare Provider Details

I. General information

NPI: 1629859582
Provider Name (Legal Business Name): GRETCHELL DELACARIDAD SUAREZ GUERRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8033 DIXIE HWY
LOUISVILLE KY
40258-1344
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-2244
US

V. Phone/Fax

Practice location:
  • Phone: 502-937-3155
  • Fax:
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4010189
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number4010189
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: