Basic Information
| Provider Information | |||||||||
| NPI: | 1003147539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLAKE | ||||||||
| FirstName: | TRICIA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4402 CHURCHMAN AVE | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402153102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023676322 | ||||||||
| FaxNumber: | 5023803843 | ||||||||
| Practice Location | |||||||||
| Address1: | 4402 CHURCHMAN AVE | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402153102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023676322 | ||||||||
| FaxNumber: | 5023803843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2010 | ||||||||
| LastUpdateDate: | 07/07/2014 | ||||||||
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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 | 63309 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.