Basic Information
| Provider Information | |||||||||
| NPI: | 1811262371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONLEY | ||||||||
| FirstName: | MARLA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 4121 DUTCHMANS LN STE 301 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028962500 | ||||||||
| FaxNumber: | 5028962527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2012 | ||||||||
| LastUpdateDate: | 07/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | 35350337 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care | 363LN0005X | 3007985 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 201207180 | 05 | IN | MEDICAID | 7100254940 | 05 | KY | MEDICAID |