Provider Demographics
NPI:1033117478
Name:BALLARD, ANGELA MARIE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1142
Mailing Address - Country:US
Mailing Address - Phone:502-348-5968
Mailing Address - Fax:502-349-0963
Practice Address - Street 1:201 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1142
Practice Address - Country:US
Practice Address - Phone:502-348-5968
Practice Address - Fax:502-349-0963
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2356P363L00000X
KY3002356363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP23341Medicare UPIN