Provider Demographics
NPI:1003189267
Name:LARA, ABBY JO (APRN)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:JO
Last Name:LARA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:THOMAS
Other - Last Name:NOISWORTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:2700 STANLEY GAULT PKWY
Mailing Address - Street 2:SUITE 129
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5132
Mailing Address - Country:US
Mailing Address - Phone:270-326-3949
Mailing Address - Fax:270-326-3954
Practice Address - Street 1:500 CLINIC DR
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-4991
Practice Address - Country:US
Practice Address - Phone:270-707-3354
Practice Address - Fax:270-707-3351
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007353363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100200240Medicaid
KY7100200240Medicaid
KYK035650Medicare PIN
KYK035651Medicare PIN
KYK035652Medicare PIN