Provider Demographics
NPI:1114356458
Name:COBLENTZ, ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:COBLENTZ
Suffix:
Gender:F
Credentials:NP
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 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7818
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:2750 BATTLEFIELD MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-8332
Practice Address - Country:US
Practice Address - Phone:859-986-0302
Practice Address - Fax:859-986-0315
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1112063363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100273450Medicaid