Healthcare Provider Details

I. General information

NPI: 1720774904
Provider Name (Legal Business Name): REBECCA MAE CAUDILL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 JAMES S TRIMBLE BLVD
PAINTSVILLE KY
41240
US

IV. Provider business mailing address

604 JAMES S TRIMBLE BLVD
PAINTSVILLE KY
41240
US

V. Phone/Fax

Practice location:
  • Phone: 606-788-0303
  • Fax: 606-788-0310
Mailing address:
  • Phone: 606-788-0303
  • Fax: 606-788-0310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3019088
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: