Provider Demographics
NPI:1922443480
Name:ETOWN FAMILY PRACTICE PLC
Entity Type:Organization
Organization Name:ETOWN FAMILY PRACTICE PLC
Other - Org Name:ETOWN FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:270-900-0192
Mailing Address - Street 1:1239 WOODLAND DR
Mailing Address - Street 2:STE 105
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2770
Mailing Address - Country:US
Mailing Address - Phone:270-900-0192
Mailing Address - Fax:
Practice Address - Street 1:1239 WOODLAND DR
Practice Address - Street 2:SUITE 105
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2770
Practice Address - Country:US
Practice Address - Phone:270-900-0192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY3007643261QP2300X
KY3007643363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1205187333OtherNPI