Provider Demographics
NPI:1427417153
Name:RICHARDSON, SHACONYA L
Entity Type:Individual
Prefix:
First Name:SHACONYA
Middle Name:L
Last Name:RICHARDSON
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 1:6007 COUNT TURF DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40272-3549
Mailing Address - Country:US
Mailing Address - Phone:502-243-5565
Mailing Address - Fax:502-772-8983
Practice Address - Street 1:714 LYNDON LN STE 6
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4643
Practice Address - Country:US
Practice Address - Phone:502-243-5565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010019363LF0000X, 363LP0808X
IN28196212A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100443600Medicaid