Provider Demographics
NPI:1982365789
Name:RICHARDSON, AMBER NICOLE (LMT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:NICOLE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 POPLAR STREET BOX A4
Mailing Address - Street 2:103B
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071
Mailing Address - Country:US
Mailing Address - Phone:270-227-6376
Mailing Address - Fax:
Practice Address - Street 1:111 POPLAR ST STE 103B
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2586
Practice Address - Country:US
Practice Address - Phone:270-227-6376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY274244225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist