=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518624659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CECILIA FOTABI DAVID APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2021
-----------------------------------------------------
Last Update Date | 11/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1916 JUSTICE DR STE 120
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-2609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-756-6837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2093 SHAKER RUN RD
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-8470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-583-3002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11210414
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------