Basic Information
Provider Information | |||||||||
NPI: | 1538413976 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EBLEN | ||||||||
FirstName: | ALISON | ||||||||
MiddleName: | DAWN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 23229 | ||||||||
Address2: |   | ||||||||
City: | OWENSBORO | ||||||||
State: | KY | ||||||||
PostalCode: | 423043229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2706881330 | ||||||||
FaxNumber: | 2706881338 | ||||||||
Practice Location | |||||||||
Address1: | 1201 PLEASANT VALLEY RD FL 3 | ||||||||
Address2: |   | ||||||||
City: | OWENSBORO | ||||||||
State: | KY | ||||||||
PostalCode: | 423039811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2704175390 | ||||||||
FaxNumber: | 2704170165 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2012 | ||||||||
LastUpdateDate: | 07/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | 71005459A | IN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 363LN0000X | 3007744 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
ID | Type | State | Issuer | Description | 201172980 | 05 | IN |   | MEDICAID |