Basic Information
| Provider Information | |||||||||
| NPI: | 1316374796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REINKE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ASHLEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOWLER | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ASHLEY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 201 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707816477 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5796 NASHVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421017546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707816477 | ||||||||
| FaxNumber: | 2706476479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2013 | ||||||||
| LastUpdateDate: | 12/22/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3009731 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 003138738D | 05 | GA | MEDICAID | 003138738C | 05 | GA | MEDICAID | MF3062407 | 01 | KY | DEA | OTHER |