Healthcare Provider Details

I. General information

NPI: 1891118865
Provider Name (Legal Business Name): KIOSK MEDICINE KENTUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 RICHMOND PLZ
RICHMOND KY
40475-2564
US

IV. Provider business mailing address

PO BOX 932958
CLEVELAND OH
44193-0028
US

V. Phone/Fax

Practice location:
  • Phone: 859-623-5155
  • Fax: 859-623-9924
Mailing address:
  • Phone: 615-425-4200
  • Fax: 615-425-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS SHELLY
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 615-425-4200