Provider Demographics
NPI:1184890535
Name:GERIATRIC NURSE PRACTITIONER SERVICES, LLC
Entity type:Organization
Organization Name:GERIATRIC NURSE PRACTITIONER SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GERONTOLOGICAL NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOLA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:HOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, GNP
Authorized Official - Phone:270-929-9971
Mailing Address - Street 1:6652 WATERFORD PL
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-9235
Mailing Address - Country:US
Mailing Address - Phone:270-929-9971
Mailing Address - Fax:270-281-4009
Practice Address - Street 1:6652 WATERFORD PL
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9235
Practice Address - Country:US
Practice Address - Phone:270-929-9971
Practice Address - Fax:270-281-4009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYARNP 2129P363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYARNP 2129POtherLICENSE
KYARNP 2129POtherLICENSE