MEDICARE: MRS. MARY LEE PANTESS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4005705	KY
2	363L00000X	Nurse Practitioner	4004705	KY
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	4004705	KY

General Provider Information

NPI Number	:	1043996911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY LEE PANTESS NP

Provider Business Mailing Address
First Line	:	817 S JACKSON ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40203-2431
Country	:	US
Telephone Number	:	502-259-8811
Fax Number	:

Provider Business Practice Location Address
First Line	:	3934 DIXIE HWY STE 420
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40216-5162
Country	:	US
Telephone Number	:	502-200-1335
Fax Number	:	866-715-7614

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2023
Last Update Date	:	01/17/2026

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