Provider Demographics
NPI:1699293670
Name:LONNEMAN, PHYLLIS K
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:K
Last Name:LONNEMAN
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 1:202 N MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1441
Mailing Address - Country:US
Mailing Address - Phone:270-312-2860
Mailing Address - Fax:270-765-2166
Practice Address - Street 1:208 N MULBERRY ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1464
Practice Address - Country:US
Practice Address - Phone:270-312-2860
Practice Address - Fax:270-312-2860
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173148101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY173148OtherCOMMONWEALTH OF KY