Provider Demographics
NPI:1801110424
Name:KAUFFMAN, SHAWNA L
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:L
Last Name:KAUFFMAN
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:PO BOX 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:12955 SHELBYVILLE RD STE 2
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243
Practice Address - Country:US
Practice Address - Phone:502-245-4301
Practice Address - Fax:502-244-5829
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY46193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000829906OtherANTHEM - NCMA
KY149563OtherSIHO - NCMA
KY50065676OtherPASSPORT
KY000000830890OtherANTHEM - NICC
KY149534OtherSIHO - NICC
KY7100179250Medicaid
KY000000830890OtherANTHEM - NICC