Provider Demographics
NPI:1720741770
Name:SHOUSE, WINIFRED ANN (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:WINIFRED
Middle Name:ANN
Last Name:SHOUSE
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1720 W BROADWAY STE 107
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-3607
Practice Address - Country:US
Practice Address - Phone:502-340-5900
Practice Address - Fax:502-394-3691
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3016815363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3016815OtherLICENSE