Basic Information
| Provider Information | |||||||||
| NPI: | 1649479460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANESE | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707815111 | ||||||||
| FaxNumber: | 2708433376 | ||||||||
| Practice Location | |||||||||
| Address1: | 1065 ASHLEY ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421033401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708433376 | ||||||||
| FaxNumber: | 2707800496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207ND0900X | 42560 | KY | Y | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 7100072860 | 05 | KY | MEDICAID |