Healthcare Provider Details

I. General information

NPI: 1508196262
Provider Name (Legal Business Name): SOUTHERN KY MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2009
Last Update Date: 12/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 JOE T PETTY DR
RUSSELL SPRINGS KY
42718
US

IV. Provider business mailing address

72 JOE T PETTY DR
RUSSELL SPRINGS KY
42718
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-4357
  • Fax: 270-858-4957
Mailing address:
  • Phone: 270-866-4357
  • Fax: 270-858-4957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number2287P
License Number StateKY

VIII. Authorized Official

Name: ANGELA CUNDIFF / ROY
Title or Position: CANP
Credential: MSN , CANP
Phone: 270-866-4357