Basic Information
| Provider Information | |||||||||
| NPI: | 1346565629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAX | ||||||||
| FirstName: | KASEY | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383020400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314255752 | ||||||||
| FaxNumber: | 7314225743 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 W MARKET STREET | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380082519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316582885 | ||||||||
| FaxNumber: | 7316582886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2010 | ||||||||
| LastUpdateDate: | 01/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 139704 | TN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 14931 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.