Basic Information
| Provider Information | |||||||||
| NPI: | 1053737973 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OVERBERG | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122 | ||||||||
| Address2: | 300 SANDRIDGE RD EAST | ||||||||
| City: | WACO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403850122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164671104 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9510 ORMSBY STATION RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402234082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2014 | ||||||||
| LastUpdateDate: | 10/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 3008565 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 7100311950 | 05 | KY | MEDICAID | 12678456 | 01 | CAQH | OTHER |