Provider Demographics
NPI:1083180905
Name:THEOBALD, ALLISON MCKENZIE (APRN)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:MCKENZIE
Last Name:THEOBALD
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 1:6500 PRESTON HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-1820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6500 PRESTON HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-1820
Practice Address - Country:US
Practice Address - Phone:502-893-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012345363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics