Basic Information
| Provider Information | |||||||||
| NPI: | 1932190212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCENROE | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 LEAF LN | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425034662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066794997 | ||||||||
| FaxNumber: | 6066795976 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 HARDIN LN | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425033814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066797348 | ||||||||
| FaxNumber: | 6066794097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 235P | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 78001484 | 05 | KY | MEDICAID |