Provider Demographics
NPI:1932190212
Name:MCENROE, SALLY R (ARNP)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:R
Last Name:MCENROE
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 1:510 LEAF LN
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-4662
Mailing Address - Country:US
Mailing Address - Phone:606-679-4997
Mailing Address - Fax:606-679-5976
Practice Address - Street 1:101 HARDIN LN
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3814
Practice Address - Country:US
Practice Address - Phone:606-679-7348
Practice Address - Fax:606-679-4097
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY235P363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78001484Medicaid
KY78001484Medicaid
02640500713Medicare ID - Type Unspecified