Healthcare Provider Details

I. General information

NPI: 1942032610
Provider Name (Legal Business Name): DEACONESS CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6071 HIGHWAY 54
PHILPOT KY
42366-9642
US

IV. Provider business mailing address

PO BOX 631767
CINCINNATI OH
45263-1767
US

V. Phone/Fax

Practice location:
  • Phone: 270-713-0177
  • Fax: 270-713-0185
Mailing address:
  • Phone: 812-450-6815
  • Fax: 812-450-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHERYL ANNETTE WATHEN
Title or Position: CFO
Credential:
Phone: 812-450-3296