Provider Demographics
NPI:1437614120
Name:KING, SAVANNAH MARIE (AG-ACNP)
Entity Type:Individual
Prefix:MRS
First Name:SAVANNAH
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4207 FRANCES DR
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-8721
Mailing Address - Country:US
Mailing Address - Phone:502-507-3311
Mailing Address - Fax:
Practice Address - Street 1:325 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1377
Practice Address - Country:US
Practice Address - Phone:270-699-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1134768363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1134768Medicaid