Basic Information
| Provider Information | |||||||||
| NPI: | 1780657015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PICKETT | ||||||||
| FirstName: | DARLA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | VANCEBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411790550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067963029 | ||||||||
| FaxNumber: | 6067966221 | ||||||||
| Practice Location | |||||||||
| Address1: | RR 3 | ||||||||
| Address2: | |||||||||
| City: | VANCEBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411799701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067963029 | ||||||||
| FaxNumber: | 6067966221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
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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 | 363AM0700X | PA836 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 9500426300 | 05 | KY | MEDICAID |