Provider Demographics
NPI:1699353086
Name:NATHALA, PAVANI
Entity type:Individual
Prefix:
First Name:PAVANI
Middle Name:
Last Name:NATHALA
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 1:100 HELMWOOD PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2975
Mailing Address - Country:US
Mailing Address - Phone:502-769-5579
Mailing Address - Fax:270-706-5547
Practice Address - Street 1:100 HELMWOOD PLAZA DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2975
Practice Address - Country:US
Practice Address - Phone:270-769-5579
Practice Address - Fax:270-706-5547
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY59684207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine