=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053977041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENM WELLNESS & MORE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2019
-----------------------------------------------------
Last Update Date | 11/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 W BROADWAY STE 4
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-2236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-963-5803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4205 NANEEN DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40216-3973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-314-1247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERICA MAHONE
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 502-314-1247
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------