Healthcare Provider Details

I. General information

NPI: 1972979540
Provider Name (Legal Business Name): FAMILY PRACTICE OF KENTUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CRESTVIEW DR
MANCHESTER KY
40962-7012
US

IV. Provider business mailing address

204 TOWN BRANCH RD
MANCHESTER KY
40962-1322
US

V. Phone/Fax

Practice location:
  • Phone: 606-594-1769
  • Fax: 606-596-0473
Mailing address:
  • Phone: 606-596-7196
  • Fax: 606-598-1903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number900342
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateKY
# 6
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. EVA A EDWARDS
Title or Position: OWNER
Credential: ARNP,FNP-BC,RFNA,CNO
Phone: 606-594-1769