Provider Demographics
NPI:1477844835
Name:LIBERTY MEDICAL CLINIC
Entity Type:Organization
Organization Name:LIBERTY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARPLE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-F
Authorized Official - Phone:606-706-4265
Mailing Address - Street 1:108 TAYLOR ST
Mailing Address - Street 2:P.O. BOX 1196
Mailing Address - City:LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:42539-3160
Mailing Address - Country:US
Mailing Address - Phone:606-706-4265
Mailing Address - Fax:606-706-4275
Practice Address - Street 1:108 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:42539-3160
Practice Address - Country:US
Practice Address - Phone:606-706-4265
Practice Address - Fax:606-706-4275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004478363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1447281712OtherNPI
KY7815765Medicaid
Q71254Medicare UPIN
1447281712Medicare PIN