Healthcare Provider Details

I. General information

NPI: 1467656876
Provider Name (Legal Business Name): MARY NICOLE MOSELEY JAEGER ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 S FLOYD ST STE 342
LOUISVILLE KY
40202-3818
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-8470
  • Fax:
Mailing address:
  • Phone: 502-588-0329
  • Fax: 502-588-0326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number1112372
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: