Basic Information
| Provider Information | |||||||||
| NPI: | 1518375443 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURRES | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12201 BLUEGRASS PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402992361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025687366 | ||||||||
| FaxNumber: | 5025687114 | ||||||||
| Practice Location | |||||||||
| Address1: | 2529 SIX MILE LN | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402202934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024915560 | ||||||||
| FaxNumber: | 5024910214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2014 | ||||||||
| LastUpdateDate: | 05/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 3008764 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 3008764 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | APN3008764 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100312070 | 05 | KY | MEDICAID |