Basic Information
Provider Information | |||||||||
NPI: | 1285822643 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WELLS | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HUTSON | ||||||||
OtherFirstName: | LORI | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 236 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MOUNT STERLING | ||||||||
State: | KY | ||||||||
PostalCode: | 403531348 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8594047686 | ||||||||
FaxNumber: | 8592744459 | ||||||||
Practice Location | |||||||||
Address1: | 209 N MAYSVILLE ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | MOUNT STERLING | ||||||||
State: | KY | ||||||||
PostalCode: | 403531179 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8594047686 | ||||||||
FaxNumber: | 8594988160 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2007 | ||||||||
LastUpdateDate: | 02/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5353P | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 7100021590 | 05 | KY |   | MEDICAID |