Healthcare Provider Details

I. General information

NPI: 1154885705
Provider Name (Legal Business Name): ELIZABETH JAYDE ISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 S KY 7
SANDY HOOK KY
41171-6830
US

IV. Provider business mailing address

845 KY 719
SANDY HOOK KY
41171-9065
US

V. Phone/Fax

Practice location:
  • Phone: 606-738-5155
  • Fax:
Mailing address:
  • Phone: 606-207-9592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC293
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: