Healthcare Provider Details

I. General information

NPI: 1740714674
Provider Name (Legal Business Name): CHELSEA MARY VIEKE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHELSEA MARY ROTH

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 MAYFAIR DR STE 101
OWENSBORO KY
42301-4569
US

IV. Provider business mailing address

PO BOX 23229
OWENSBORO KY
42304-3229
US

V. Phone/Fax

Practice location:
  • Phone: 270-688-1352
  • Fax: 270-683-4313
Mailing address:
  • Phone: 270-688-1330
  • Fax: 270-688-1338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3011415
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1137585
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: