Healthcare Provider Details

I. General information

NPI: 1295461119
Provider Name (Legal Business Name): RED MAPLE PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 NASHVILLE ST STE 106
RUSSELLVILLE KY
42276-8871
US

IV. Provider business mailing address

1621 NASHVILLE ST STE 106
RUSSELLVILLE KY
42276-8871
US

V. Phone/Fax

Practice location:
  • Phone: 270-946-1372
  • Fax: 270-216-6185
Mailing address:
  • Phone: 270-946-1372
  • Fax: 270-216-6185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE KENNEDY-FOSTER
Title or Position: MD
Credential: MD
Phone: 270-438-6622