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General NPI Number Information
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NPI Number | 1922443480
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Entity Type | Organization
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Legal Business Name | ETOWN FAMILY PRACTICE PLC
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Dates
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Enumeration Date | 05/09/2013
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Last Update Date | 12/02/2014
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Provider Practice Location Address
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Address Line | 1239 WOODLAND DR SUITE 105
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-2770
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Country | US
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Telephone | 270-900-0192
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Fax |
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Provider Business Mailing Address
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Address Line | 1239 WOODLAND DR STE 105
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-2770
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Country | US
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Telephone | 270-900-0192
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Fax |
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Authorized Official
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Title or Position | APRN
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Name | GWEN THOMAS
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Credential | APRN
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Telephone | 270-900-0192
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | KY3007643
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 3007643
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License Number State | KY
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