Provider Demographics
NPI:1891005955
Name:FONSECA, JODY
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:FONSECA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W. MUHAMMAD ALI BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1451
Mailing Address - Country:US
Mailing Address - Phone:502-589-6000
Mailing Address - Fax:502-589-8711
Practice Address - Street 1:708 MAGAZINE ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2043
Practice Address - Country:US
Practice Address - Phone:502-589-6000
Practice Address - Fax:502-589-8771
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2032302164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse