Basic Information
| Provider Information | |||||||||
| NPI: | 1003291360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOOM | ||||||||
| FirstName: | JEANIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 JH OBRYAN AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RIVERS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420459049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703628246 | ||||||||
| FaxNumber: | 2703629757 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 JH OBRYAN AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RIVERS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420459049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703628246 | ||||||||
| FaxNumber: | 2703629757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2015 | ||||||||
| LastUpdateDate: | 07/28/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3009544 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3009544 | 01 | KY | APRN LICENSE | OTHER |