Basic Information
Provider Information | |||||||||
NPI: | 1588909287 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLLAND | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | KUSTES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KUSTES | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | KATHERINE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APRN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 950244 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402950244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5029534700 | ||||||||
FaxNumber: | 5027728189 | ||||||||
Practice Location | |||||||||
Address1: | 2215 PORTLAND AVE | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402121033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5027748631 | ||||||||
FaxNumber: | 5027728189 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2012 | ||||||||
LastUpdateDate: | 04/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0185113 | CO | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | 1133433 | KY | N |   | Nursing Service Providers | Registered Nurse |   | 363LW0102X | 3007804 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
ID | Type | State | Issuer | Description | 7100349330 | 05 | KY |   | MEDICAID |