Basic Information
| Provider Information | |||||||||
| NPI: | 1548916810 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHACONYA L RICHARDSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6007 COUNT TURF DR | ||||||||
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| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402723549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022435565 | ||||||||
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| Practice Location | |||||||||
| Address1: | 714 LYNDON LN STE 6 | ||||||||
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| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402224643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022254900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2022 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING AGENT | ||||||||
| AuthorizedOfficialTelephone: | 5026543927 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.