Provider Demographics
NPI:1114531803
Name:MLACK, KARALEE ANN
Entity Type:Individual
Prefix:
First Name:KARALEE
Middle Name:ANN
Last Name:MLACK
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 1:740 SOUTH LIMESTONE K401
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0284
Mailing Address - Country:US
Mailing Address - Phone:859-323-5533
Mailing Address - Fax:859-323-2412
Practice Address - Street 1:740 SOUTH LIMESTONE
Practice Address - Street 2:K401
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0284
Practice Address - Country:US
Practice Address - Phone:859-323-5533
Practice Address - Fax:859-323-2412
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014780363LA2100X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty