Basic Information
| Provider Information | |||||||||
| NPI: | 1891141529 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLEY | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950112 | ||||||||
| Address2: | DEPT # 52387 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777836257 | ||||||||
| FaxNumber: | 8595145521 | ||||||||
| Practice Location | |||||||||
| Address1: | 913 N DIXIE AVE | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427012503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777836257 | ||||||||
| FaxNumber: | 8595145521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2016 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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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 | 363LF0000X | 3010142 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3010142 | 01 | KY | MEDICAL LICENSE | OTHER |