Basic Information
| Provider Information | |||||||||
| NPI: | 1962638296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCONATHY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ELISE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 ALUMNI PARK PLZ | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405174012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592577910 | ||||||||
| FaxNumber: | 8592577987 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 ROSE ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593235956 | ||||||||
| FaxNumber: | 8593231080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2009 | ||||||||
| LastUpdateDate: | 04/17/2012 | ||||||||
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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 | 4195P | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 364S00000X | 4195P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
ID Information
| ID | Type | State | Issuer | Description | 78011194 | 05 | KY | MEDICAID |