Provider Demographics
NPI:1508973439
Name:FUNK, JAN J (APRN, BC)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:J
Last Name:FUNK
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 FAIRVIEW AVE STE A8
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2383
Mailing Address - Country:US
Mailing Address - Phone:270-796-2550
Mailing Address - Fax:
Practice Address - Street 1:730 FAIRVIEW AVE STE A8
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2383
Practice Address - Country:US
Practice Address - Phone:270-796-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007542364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME289840099Medicaid