Basic Information
| Provider Information | |||||||||
| NPI: | 1720275332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASEY | ||||||||
| FirstName: | RHONDA | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DERRICKS | ||||||||
| OtherFirstName: | RHONDA | ||||||||
| OtherMiddleName: | A.R. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1930 BISHOP LN | ||||||||
| Address2: | SUITE 1017 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402181921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022725754 | ||||||||
| FaxNumber: | 5022725339 | ||||||||
| Practice Location | |||||||||
| Address1: | 3991 DUTCHMANS LN | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028993366 | ||||||||
| FaxNumber: | 5028993455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2007 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | 3005372 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
ID Information
| ID | Type | State | Issuer | Description | P01100047 | 01 | KY | RR MEDICARE | OTHER | 200888200 | 05 | IN | MEDICAID | 7100023800 | 05 | KY | MEDICAID | 50017921 | 01 | PASSPORT | OTHER |