Provider Demographics
NPI:1780657015
Name:PICKETT, DARLA J (PAC)
Entity Type:Individual
Prefix:
First Name:DARLA
Middle Name:J
Last Name:PICKETT
Suffix:
Gender:F
Credentials:PAC
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 550
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-0550
Mailing Address - Country:US
Mailing Address - Phone:606-796-3029
Mailing Address - Fax:606-796-6221
Practice Address - Street 1:RR 3
Practice Address - Street 2:
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179-9701
Practice Address - Country:US
Practice Address - Phone:606-796-3029
Practice Address - Fax:606-796-6221
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA836363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9500426300Medicaid
KYQ14945Medicare UPIN
KY9500426300Medicaid