=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649991662
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENDRA DENISE SUBLETT MSN, APRN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2022
-----------------------------------------------------
Last Update Date | 01/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 KINGSWOOD DR
-----------------------------------------------------
City | CAMPBELLSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42718-9634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-789-1112
-----------------------------------------------------
Fax | 270-789-6176
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1698 OLD LEBANON RD
-----------------------------------------------------
City | CAMPBELLSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42718-3319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-789-6087
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 3018315
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 3018315
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------