Healthcare Provider Details

I. General information

NPI: 1538700950
Provider Name (Legal Business Name): REX DEWAN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S JACKSON ST
LOUISVILLE KY
40202-1622
US

IV. Provider business mailing address

401 E CHESTNUT ST UNIT 600
LOUISVILLE KY
40202-5705
US

V. Phone/Fax

Practice location:
  • Phone: 502-562-3120
  • Fax: 502-588-4427
Mailing address:
  • Phone: 502-588-4425
  • Fax: 502-588-4427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3013925
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: