Provider Demographics
NPI:1790735306
Name:HALE, NANCY MAE (PA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:MAE
Last Name:HALE
Suffix:
Gender:F
Credentials:PA
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 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7840
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:118 PATRIOT DR
Practice Address - Street 2:SUITE 102
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-9093
Practice Address - Country:US
Practice Address - Phone:502-350-1022
Practice Address - Fax:502-350-1023
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA513363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95000667Medicaid
KY00013008Medicare PIN
KYP25520Medicare UPIN
KYK093970Medicare PIN
0661612Medicare ID - Type Unspecified