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General NPI Number Information
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NPI Number | 1497232722
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Entity Type | Organization
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Legal Business Name | SOUTH SHORE FAMILY MEDICAL CLINIC
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Dates
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Enumeration Date | 07/19/2018
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Last Update Date | 07/19/2018
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Provider Practice Location Address
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Address Line | 74 BIGGS LN
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City | SOUTH SHORE
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State | KY
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Zip | 41175-7846
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Country | US
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Telephone | 606-498-4232
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Fax |
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Provider Business Mailing Address
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Address Line | 37 CHRISTOPHER DR
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City | SOUTH SHORE
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State | KY
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Zip | 41175-9447
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Country | US
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Telephone | 594-210-4458
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Fax |
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Authorized Official
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Title or Position | FNP
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Name | JAMES LEE RYAN
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Credential | NURSE PRACTITIONER
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Telephone | 606-498-4232
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 3006463
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License Number State | KY
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