Healthcare Provider Details

I. General information

NPI: 1588073886
Provider Name (Legal Business Name): TERESA KEITH COLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2014
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 MEMORIAL DR STE 2
MANCHESTER KY
40962-6196
US

IV. Provider business mailing address

509 MEMORIAL DR STE 2
MANCHESTER KY
40962-6196
US

V. Phone/Fax

Practice location:
  • Phone: 606-598-5104
  • Fax: 606-598-0983
Mailing address:
  • Phone: 606-598-5104
  • Fax: 606-598-0983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3008855
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3008855
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: