Provider Demographics
NPI:1942825658
Name:WILLOW TREE PEDIATRICS OF LEXINGTON
Entity Type:Organization
Organization Name:WILLOW TREE PEDIATRICS OF LEXINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:DENISON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:859-286-9046
Mailing Address - Street 1:2036 REGENCY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2309
Mailing Address - Country:US
Mailing Address - Phone:859-286-9046
Mailing Address - Fax:859-276-3726
Practice Address - Street 1:2036 REGENCY RD STE 2
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2309
Practice Address - Country:US
Practice Address - Phone:859-286-9046
Practice Address - Fax:859-276-3726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100622640Medicaid
KY7100622640Medicaid