Provider Demographics
NPI:1104684398
Name:WILLOUGHBY, DAVID JONATHON (LPN)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JONATHON
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:EMINENCE
Mailing Address - State:KY
Mailing Address - Zip Code:40019-1300
Mailing Address - Country:US
Mailing Address - Phone:502-706-8643
Mailing Address - Fax:
Practice Address - Street 1:4922 POPLAR LEVEL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-1128
Practice Address - Country:US
Practice Address - Phone:502-434-5566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2049631164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse