Healthcare Provider Details

I. General information

NPI: 1902928898
Provider Name (Legal Business Name): LADIES CLINIC , PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 BOGLE ST STE A
SOMERSET KY
42503-2873
US

IV. Provider business mailing address

347 BOGLE ST STE A
SOMERSET KY
42503-2873
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-7353
  • Fax:
Mailing address:
  • Phone: 606-679-7353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number23151
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1358P
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number5888P
License Number StateKY

VIII. Authorized Official

Name: DENNIS R FAULKNER
Title or Position: PRESIDENT
Credential: MD
Phone: 606-679-7353