Basic Information
Provider Information | |||||||||
NPI: | 1790063592 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | UTSEY | ||||||||
FirstName: | SANDRA | ||||||||
MiddleName: | ELDER | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ELDER | ||||||||
OtherFirstName: | SANDRA | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 950202 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402950202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025889490 | ||||||||
FaxNumber: | 5022725116 | ||||||||
Practice Location | |||||||||
Address1: | 200 E CHESTNUT ST STE 303 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402021831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5026295552 | ||||||||
FaxNumber: | 5026293132 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2011 | ||||||||
LastUpdateDate: | 01/23/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1076668 | KY | N |   | Nursing Service Providers | Registered Nurse |   | 363L00000X | 3006888 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 000057121KD | 01 | KY | HUMANA - NRP | OTHER | 201034670 | 05 | IN |   | MEDICAID | 7100183390 | 05 | KY |   | MEDICAID | 000000726728 | 01 | KY | ANTHEM - NRP | OTHER | 127895 | 01 | KY | SIHO - NRP | OTHER | 50034295 | 01 | KY | PASSPORT - NRP | OTHER |