Provider Demographics
NPI:1699863514
Name:PHELPS, KATHY DIANNE (APRN FNP)
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:DIANNE
Last Name:PHELPS
Suffix:
Gender:F
Credentials:APRN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1175
Mailing Address - Street 2:
Mailing Address - City:CALVERT CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42029
Mailing Address - Country:US
Mailing Address - Phone:270-395-5388
Mailing Address - Fax:270-395-1792
Practice Address - Street 1:3131 PARISA DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-4584
Practice Address - Country:US
Practice Address - Phone:270-444-8000
Practice Address - Fax:270-444-8302
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3143P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78015690Medicaid
000000340382OtherANTHEM
P51549Medicare UPIN
KY78015690Medicaid