Provider Demographics
NPI:1316029507
Name:CLIFFORD, THERESA LYNN (FNP, APRN)
Entity Type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:LYNN
Last Name:CLIFFORD
Suffix:
Gender:F
Credentials:FNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-633-4622
Mailing Address - Fax:502-633-6925
Practice Address - Street 1:60 MACK WALTERS RD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1738
Practice Address - Country:US
Practice Address - Phone:502-633-4622
Practice Address - Fax:502-633-6925
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002154363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000626807OtherANTHEM
KY3722988000OtherPASSPORT ADVANTAGE
KY7100078250Medicaid
KY50024463OtherPASSPORT
KY000000626807OtherANTHEM
KY50024463OtherPASSPORT
KYP65722Medicare UPIN