Basic Information
Provider Information | |||||||||
NPI: | 1831721323 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PERKINS | ||||||||
FirstName: | TERESA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5722 OUTER LOOP | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402194156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5024927455 | ||||||||
FaxNumber: | 5029210222 | ||||||||
Practice Location | |||||||||
Address1: | 1327 E BROADWAY ST STE B | ||||||||
Address2: |   | ||||||||
City: | CAMPBELLSVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 427181599 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2702834240 | ||||||||
FaxNumber: | 2702834556 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2020 | ||||||||
LastUpdateDate: | 04/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3014292 | KY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X | 3014292 | KY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X | 3014292 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 7100650000 | 05 | KY |   | MEDICAID |