Provider Demographics
NPI:1780909952
Name:DISMORE WRINKLES, JENNA LEIGH (MD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LEIGH
Last Name:DISMORE WRINKLES
Suffix:
Gender:F
Credentials:MD
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 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:1107 CROWN POINTE DR STE 107
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7280
Practice Address - Country:US
Practice Address - Phone:270-506-3300
Practice Address - Fax:270-506-2843
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075865A207LP2900X
KY47108207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01957674OtherRAILROAD MEDICARE
KY1232438OtherWELLCARE OF KY PROVIDER ID NUMBER
IN201317930Medicaid
KYP01590218OtherRAILROAD MEDICARE
5661958OtherAETNA PIN
CS1612000141OtherCARESOURCE ID
005625439OtherUNITED HEALTHCARE PROVIDER ID NUMBER
000000963791OtherANTHEM PIN
KY339847KYIPOtherAETNA BETTER HEALTH OF KY PROVIDER ID NUMBER
2355628OtherCIGNA PROVIDER ID NUMBER
KY7100167720Medicaid