Provider Demographics
NPI:1750665162
Name:CARRICO CONGLETON FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:CARRICO CONGLETON FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARRICO
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:270-215-0234
Mailing Address - Street 1:2811 NEW HARTFORD RD STE B
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1384
Mailing Address - Country:US
Mailing Address - Phone:270-215-0234
Mailing Address - Fax:270-215-0316
Practice Address - Street 1:2811 NEW HARTFORD ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1320
Practice Address - Country:US
Practice Address - Phone:270-215-0234
Practice Address - Fax:270-215-0316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-04
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty