Basic Information
| Provider Information | |||||||||
| NPI: | 1275189508 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPAGNOLETTI | ||||||||
| FirstName: | JACKLYN | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 187 WOLFORD AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425393278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067876275 | ||||||||
| FaxNumber: | 6067870251 | ||||||||
| Practice Location | |||||||||
| Address1: | CASEY COUNTY PRIMARY CARE | ||||||||
| Address2: | 187 WOLFORD AVENUE | ||||||||
| City: | LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425393278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067878348 | ||||||||
| FaxNumber: | 6067870251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2019 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3013711 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.