Provider Demographics
NPI:1255942959
Name:STANVILLE AFTER HOURS CLINIC LLC
Entity type:Organization
Organization Name:STANVILLE AFTER HOURS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WILMA
Authorized Official - Middle Name:
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-478-5500
Mailing Address - Street 1:9405 US HIGHWAY 23 S STE 1
Mailing Address - Street 2:
Mailing Address - City:STANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41659-9048
Mailing Address - Country:US
Mailing Address - Phone:606-478-5500
Mailing Address - Fax:606-478-5501
Practice Address - Street 1:9405 US HIGHWAY 23 S STE 1
Practice Address - Street 2:
Practice Address - City:STANVILLE
Practice Address - State:KY
Practice Address - Zip Code:41659-9048
Practice Address - Country:US
Practice Address - Phone:606-478-5500
Practice Address - Fax:606-478-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-14
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78001898Medicaid
KYK091560OtherP-TAN