Basic Information
| Provider Information | |||||||||
| NPI: | 1528148749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABELL | ||||||||
| FirstName: | DOMINIQUE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BECKUM | ||||||||
| OtherFirstName: | DOMINIQUE | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307840 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 4359 NEW SHEPHERDSVILLE RD UNIT 100 | ||||||||
| Address2: | |||||||||
| City: | BARDSTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400048002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023505700 | ||||||||
| FaxNumber: | 5023505701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 4964P | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 7801829800 | 05 | KY | MEDICAID |