Basic Information
| Provider Information | |||||||||
| NPI: | 1376992537 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAUDILL | ||||||||
| FirstName: | CHRISTA | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 N MAYSVILLE ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MOUNT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403531179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594047686 | ||||||||
| FaxNumber: | 8594988160 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 N MAYSVILLE ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MOUNT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403531179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594047686 | ||||||||
| FaxNumber: | 8594988160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2016 | ||||||||
| LastUpdateDate: | 09/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | XXXXXXX | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100417320 | 05 | KY | MEDICAID |