Basic Information
Provider Information | |||||||||
NPI: | 1518948769 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLETCHER-GREEN | ||||||||
FirstName: | CARMELA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1306 VERSAILLES RD STE 120 | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405041795 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592592635 | ||||||||
FaxNumber: | 5925478748 | ||||||||
Practice Location | |||||||||
Address1: | 1306 VERSAILLES RD STE 120 | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405041795 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592592635 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2005 | ||||||||
LastUpdateDate: | 06/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA304 | KY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA304 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 11478958 | 01 | KY | CAQH | OTHER | 95002937 | 05 | KY |   | MEDICAID | 970021336 | 01 | KY | RAILROAD MEDICARE | OTHER |