Provider Demographics
NPI:1255480323
Name:BACCUS, ANNETTE H (ARNP)
Entity Type:Individual
Prefix:MS
First Name:ANNETTE
Middle Name:H
Last Name:BACCUS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S 8TH ST
Mailing Address - Street 2:SUITE 107E
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2400
Mailing Address - Country:US
Mailing Address - Phone:270-753-9240
Mailing Address - Fax:270-767-3629
Practice Address - Street 1:300 S 8TH ST
Practice Address - Street 2:SUITE 107E
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2400
Practice Address - Country:US
Practice Address - Phone:270-753-9240
Practice Address - Fax:270-767-3629
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1051957 4041P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000296656OtherANTHEM BCBS
KYP91748Medicare UPIN
KY000000296656OtherANTHEM BCBS