Provider Demographics
NPI:1417332032
Name:PHELPS, KRISTI (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:PHELPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTI
Other - Middle Name:NICOLE
Other - Last Name:DOLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1401 HARRODSBURG RD STE C100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1780
Mailing Address - Country:US
Mailing Address - Phone:859-278-4960
Mailing Address - Fax:859-277-2840
Practice Address - Street 1:1401 HARRODSBURG RD STE C100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1780
Practice Address - Country:US
Practice Address - Phone:859-278-4960
Practice Address - Fax:859-277-2840
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004397RX363A00000X
KYTC552363A00000X
KYPA2188363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0139671Medicaid
KYK220910Medicare PIN
OHH380300Medicare PIN