Provider Demographics
NPI:1639272776
Name:HARRIS, THERESA CATHERINE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:CATHERINE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 MANOR AVE
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-3230
Mailing Address - Country:US
Mailing Address - Phone:502-349-9999
Mailing Address - Fax:502-349-9499
Practice Address - Street 1:114 MANOR AVE
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-3230
Practice Address - Country:US
Practice Address - Phone:502-349-9999
Practice Address - Fax:502-349-9499
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3079P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78005097Medicaid
KY78005097Medicaid
P22296Medicare UPIN