Provider Demographics
NPI:1417494394
Name:SPURGEON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SPURGEON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE BLDG 1
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1277
Mailing Address - Country:US
Mailing Address - Phone:859-253-1686
Mailing Address - Fax:
Practice Address - Street 1:1351 NEWTOWN PIKE BLDG 1
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-1277
Practice Address - Country:US
Practice Address - Phone:859-253-1686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
KY225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid