Provider Demographics
NPI:1962759274
Name:WOODROME-NETHERY, TINA MARIE (APRN)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:WOODROME-NETHERY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:WOODROME-NETHERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-543-4119
Mailing Address - Fax:502-543-1462
Practice Address - Street 1:2205 GREENTREE N
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129
Practice Address - Country:US
Practice Address - Phone:812-283-4441
Practice Address - Fax:812-288-2605
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1105062363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201213260Medicaid
ININ2570016OtherMEDICARE