Basic Information
| Provider Information | |||||||||
| NPI: | 1841279908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWLESS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 105 GREENBRIAR DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704653595 | ||||||||
| FaxNumber: | 8592594063 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 GREENBRIAR DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CAMPBELLSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427189615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704653595 | ||||||||
| FaxNumber: | 8592594063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
| 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 | 231H00000X | 117 | KY | N | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | 279 | KY | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 000000050374 | 01 | KY | ANTHEM | OTHER | 1189065 | 01 | UNITED HEALTHCARE | OTHER | 5000-2799 | 05 | KY | MEDICAID | 7000117700 | 05 | KY | MEDICAID | 000001189065 | 01 | CHA | OTHER | 5090-0000 | 05 | KY | MEDICAID |