Provider Demographics
NPI:1093200743
Name:LAND, EMILY RENEE'
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:RENEE'
Last Name:LAND
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 1:43 GROSS LOOP
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-8625
Mailing Address - Country:US
Mailing Address - Phone:606-560-1227
Mailing Address - Fax:
Practice Address - Street 1:420 JETT DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-9621
Practice Address - Country:US
Practice Address - Phone:606-666-2456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY168904225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherN/A