MEDICARE: NORTHERN KENTUCKY UNIVERSITY FOUNDATION INC.

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

General Provider Information

NPI Number	:	1194123687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN KENTUCKY UNIVERSITY FOUNDATION INC.

Provider Business Mailing Address
First Line	:	206 ALBRIGHT HEALTH CTR
Second Line	:	NORTHERN KY UNIVERSITY
City	:	NEWPORT
State	:	KY
Zip	:	41099-0001
Country	:	US
Telephone Number	:	859-572-5579
Fax Number	:	859-572-1934

Provider Business Practice Location Address
First Line	:	206 ALBRIGHT HEALTH CTR
Second Line	:	NORTHERN KY UNIVERSITY
City	:	NEWPORT
State	:	KY
Zip	:	41099-0001
Country	:	US
Telephone Number	:	859-572-5579
Fax Number	:	859-572-1934

Authorized Official
Title or Position	:	DIRECTOR
Name	:	KRIS PFENDT
Credential	:
Telephone Number	:	859-912-0597

Provider Enumeration Date	:	12/15/2014
Last Update Date	:	12/15/2014

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