Provider Demographics
NPI:1629536297
Name:MUNCY, JACQUELINE SUE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUE
Last Name:MUNCY
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 1:8442 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-1140
Mailing Address - Country:US
Mailing Address - Phone:502-638-4280
Mailing Address - Fax:502-638-4281
Practice Address - Street 1:8442 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-1140
Practice Address - Country:US
Practice Address - Phone:502-638-4280
Practice Address - Fax:502-638-4281
Is Sole Proprietor?:No
Enumeration Date:2019-03-03
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008811B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner