Provider Demographics
NPI:1033600416
Name:SOUTHEAST FAMILY PRACTICE PSC
Entity Type:Organization
Organization Name:SOUTHEAST FAMILY PRACTICE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAMPAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-654-6210
Mailing Address - Street 1:222 W TENNESSEE AVE
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-1737
Mailing Address - Country:US
Mailing Address - Phone:606-499-5135
Mailing Address - Fax:606-654-6220
Practice Address - Street 1:222 W TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-1737
Practice Address - Country:US
Practice Address - Phone:606-499-5135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty