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General NPI Number Information
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NPI Number | 1659554079
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Entity Type | Organization
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Legal Business Name | MARSHALL COUNTY FAMILY MEDICAL CENTER NURSE PRACTITIONER GROUP
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Dates
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Enumeration Date | 12/07/2007
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Last Update Date | 12/07/2007
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Provider Practice Location Address
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Address Line | 145 VINE ST # 569
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City | BENTON
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State | KY
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Zip | 42025-7472
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Country | US
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Telephone | 270-527-2273
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Fax |
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Provider Business Mailing Address
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Address Line | 145 VINE ST PO BOX 569
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City | BENTON
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State | KY
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Zip | 42025-7472
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Country | US
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Telephone | 270-527-2273
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MARSHA R TUCKER
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Credential |
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Telephone | 270-527-2273
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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 | 4072P
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License Number State | KY
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