=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225038086
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY R RICHARDSON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2005
-----------------------------------------------------
Last Update Date | 08/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 ZORN AVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40206-1433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 29-563-4525
-----------------------------------------------------
Fax | 270-735-1978
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 914 N DIXIE AVE SUITE 304
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42701-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-769-1049
-----------------------------------------------------
Fax | 270-735-1978
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA816
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------