Provider Demographics
NPI:1962598557
Name:SNODGRASS, TINA L (APRN, FNP-C)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:L
Last Name:SNODGRASS
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 N MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-8955
Mailing Address - Country:US
Mailing Address - Phone:270-926-0707
Mailing Address - Fax:
Practice Address - Street 1:1219 N MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-8955
Practice Address - Country:US
Practice Address - Phone:270-926-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002620363LF0000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK030132OtherMEDICARE PTAN
KYK080520OtherMEDICARE GROUP PTAN
KYK030132OtherMEDICARE PTAN
KY7800330800Medicaid