Provider Demographics
NPI:1043761505
Name:EBBITT, KATHLEEN M (APRN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:EBBITT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-4450
Mailing Address - Fax:859-258-4039
Practice Address - Street 1:740 S LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-2701
Practice Address - Country:US
Practice Address - Phone:859-218-1632
Practice Address - Fax:859-257-7799
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010575363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0169Medicare PIN