Provider Demographics
NPI:1265908594
Name:CONLEY, CHASTITY
Entity type:Individual
Prefix:
First Name:CHASTITY
Middle Name:
Last Name:CONLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHASTITY
Other - Middle Name:
Other - Last Name:MAYNARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 911174
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40591-1174
Mailing Address - Country:US
Mailing Address - Phone:859-554-5067
Mailing Address - Fax:859-818-0324
Practice Address - Street 1:168 E REYNOLDS RD STE 130
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-1317
Practice Address - Country:US
Practice Address - Phone:859-554-5067
Practice Address - Fax:859-818-0324
Is Sole Proprietor?:No
Enumeration Date:2018-10-14
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012794363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100566900Medicaid