Provider Demographics
NPI:1700464278
Name:MCMAHAN, KORA
Entity Type:Individual
Prefix:
First Name:KORA
Middle Name:
Last Name:MCMAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 CRESTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-3324
Mailing Address - Country:US
Mailing Address - Phone:502-681-5356
Mailing Address - Fax:
Practice Address - Street 1:1700 CARGO CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1938
Practice Address - Country:US
Practice Address - Phone:502-681-5356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2055772164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2055772Medicaid