Healthcare Provider Details

I. General information

NPI: 1043974710
Provider Name (Legal Business Name): ALLEN DARRELL PROBUS JR. FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

896 S HIGHWAY 25W
WILLIAMSBURG KY
40769
US

IV. Provider business mailing address

460 FOREST AVE
WILLIAMSBURG KY
40769-2042
US

V. Phone/Fax

Practice location:
  • Phone: 606-376-9700
  • Fax:
Mailing address:
  • Phone: 352-650-5487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3016881
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: