Basic Information
| Provider Information | |||||||||
| NPI: | 1649788514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALMER | ||||||||
| FirstName: | TRICIA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 W BROADWAY STE 202 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025610943 | ||||||||
| FaxNumber: | 5025610944 | ||||||||
| Practice Location | |||||||||
| Address1: | 645 S ROY WILKINS AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402032072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025610520 | ||||||||
| FaxNumber: | 5025610521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2018 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704372441 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 3012431 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100539660 | 05 | KY | MEDICAID |