Healthcare Provider Details

I. General information

NPI: 1629267315
Provider Name (Legal Business Name): STEPHANIE N. SOUTHARD, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 06/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 N MAIN ST SUITE 2
MONTICELLO KY
42633-2900
US

IV. Provider business mailing address

1215 N MAIN ST SUITE 2
MONTICELLO KY
42633-2900
US

V. Phone/Fax

Practice location:
  • Phone: 606-340-8825
  • Fax: 606-340-0097
Mailing address:
  • Phone: 606-340-8825
  • Fax: 606-340-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number02809
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHANIE NICOLE SOUTHARD
Title or Position: PRESIDENT
Credential: D.O.
Phone: 606-340-8825