Provider Demographics
NPI:1679745137
Name:IDLE, JOYCE M
Entity Type:Individual
Prefix:MRS
First Name:JOYCE
Middle Name:M
Last Name:IDLE
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 1:9718 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:VAN LEAR
Mailing Address - State:KY
Mailing Address - Zip Code:41265-8456
Mailing Address - Country:US
Mailing Address - Phone:606-889-8529
Mailing Address - Fax:
Practice Address - Street 1:9718 LAKE RD
Practice Address - Street 2:
Practice Address - City:VAN LEAR
Practice Address - State:KY
Practice Address - Zip Code:41265-8456
Practice Address - Country:US
Practice Address - Phone:606-889-8529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35-2328328Medicaid