Basic Information
| Provider Information | |||||||||
| NPI: | 1548471741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEARMOND | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNFA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1206 MEADOWRIDGE TRL | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400269517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022283175 | ||||||||
| FaxNumber: | 5022283175 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 KRESGE WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028951995 | ||||||||
| FaxNumber: | 5028956479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2007 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 1039846 | KY | Y | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.