Provider Demographics
NPI:1730120429
Name:METRICK, MARY JO (ARNP MSN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:METRICK
Suffix:
Gender:F
Credentials:ARNP MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0329
Mailing Address - Fax:502-588-0326
Practice Address - Street 1:571 S FLOYD ST
Practice Address - Street 2:STE 342
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3818
Practice Address - Country:US
Practice Address - Phone:502-852-8470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1040956363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78007366Medicaid