Provider Demographics
NPI:1063488690
Name:MACKEY, POLLY KAELIN (APRN)
Entity Type:Individual
Prefix:MS
First Name:POLLY
Middle Name:KAELIN
Last Name:MACKEY
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:PO BOX 950244
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0244
Mailing Address - Country:US
Mailing Address - Phone:502-774-8631
Mailing Address - Fax:502-778-3499
Practice Address - Street 1:4100 TAYLOR BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-2342
Practice Address - Country:US
Practice Address - Phone:502-366-4747
Practice Address - Fax:502-996-8309
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3000536363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7800163300Medicaid
KY007140049Medicare PIN
KY0538693Medicare PIN