Provider Demographics
NPI:1609130376
Name:HAYDEN, TAMARA RENEE
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:RENEE
Last Name:HAYDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TAMARA
Other - Middle Name:RENEE
Other - Last Name:MATHERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 36218
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40233-6218
Mailing Address - Country:US
Mailing Address - Phone:502-634-6767
Mailing Address - Fax:502-634-6775
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217
Practice Address - Country:US
Practice Address - Phone:502-634-6767
Practice Address - Fax:502-634-6775
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007457363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100251850Medicaid
KYK059101OtherMEDICARE