Provider Demographics
NPI:1699472324
Name:NDETA, SERGE
Entity type:Individual
Prefix:
First Name:SERGE
Middle Name:
Last Name:NDETA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 REDDING RD APT 113
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-2356
Mailing Address - Country:US
Mailing Address - Phone:405-881-7317
Mailing Address - Fax:
Practice Address - Street 1:80 CODELL DR STE 140
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1177
Practice Address - Country:US
Practice Address - Phone:859-788-7882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017475363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health