Provider Demographics
NPI:1205207131
Name:CANNADY, JAMIE L (NP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:CANNADY
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 1:100 MALLARD CREEK RD STE 320
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-5136
Mailing Address - Country:US
Mailing Address - Phone:502-855-6125
Mailing Address - Fax:502-394-1972
Practice Address - Street 1:100 MALLARD CREEK RD STE 320
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5136
Practice Address - Country:US
Practice Address - Phone:502-855-6125
Practice Address - Fax:502-394-1972
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172927363L00000X
KY3016421363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN