Basic Information
Provider Information | |||||||||
NPI: | 1164063582 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRYSON | ||||||||
FirstName: | KAITLYN | ||||||||
MiddleName: | KOWALSKI | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KOWALSKI | ||||||||
OtherFirstName: | KAITLYN | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHARMD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 800 ROSE ST # H110 | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405360316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592571000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 800 ROSE ST | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405360316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592576006 | ||||||||
FaxNumber: | 8592576002 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/07/2019 | ||||||||
LastUpdateDate: | 09/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835X0200X | 021286 | KY | Y |   | Pharmacy Service Providers | Pharmacist | Oncology |
No ID Information.