Provider Demographics
NPI:1891171724
Name:FARLESS, CHELSEY
Entity Type:Individual
Prefix:
First Name:CHELSEY
Middle Name:
Last Name:FARLESS
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:PO BOX 636961
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6961
Mailing Address - Country:US
Mailing Address - Phone:888-696-3541
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:97 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:KUTTAWA
Practice Address - State:KY
Practice Address - Zip Code:42055-6285
Practice Address - Country:US
Practice Address - Phone:270-388-4357
Practice Address - Fax:270-388-4184
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009537363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100377100Medicaid
KY3009537OtherSTATE LICENSE
KYK167890Medicare PIN