Provider Demographics
NPI:1386001196
Name:COMMONWEALTH FAMILY CARE PLLC
Entity Type:Organization
Organization Name:COMMONWEALTH FAMILY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:502-403-0007
Mailing Address - Street 1:7410 NEW LA GRANGE RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4871
Mailing Address - Country:US
Mailing Address - Phone:502-742-0460
Mailing Address - Fax:502-742-9340
Practice Address - Street 1:7410 NEW LA GRANGE RD
Practice Address - Street 2:SUITE 125
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4871
Practice Address - Country:US
Practice Address - Phone:502-742-0460
Practice Address - Fax:502-742-9340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002841363L00000X
KY3006986363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK019233Medicare PIN