Provider Demographics
NPI:1811572530
Name:DERBY CITY MEDICAL PARTNERS, LLC
Entity Type:Organization
Organization Name:DERBY CITY MEDICAL PARTNERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER APRN
Authorized Official - Prefix:
Authorized Official - First Name:LATONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:502-302-9241
Mailing Address - Street 1:2902 BARDSTOWN RD STE D
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3066
Mailing Address - Country:US
Mailing Address - Phone:502-808-1048
Mailing Address - Fax:949-561-4663
Practice Address - Street 1:2902 BARDSTOWN RD STE D
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3066
Practice Address - Country:US
Practice Address - Phone:502-808-1048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-15
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100613820Medicaid
KY7100733400Medicaid
KY7100624280Medicaid