Basic Information
| Provider Information | |||||||||
| NPI: | 1851835854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NALLY | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | |||||||||
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| OtherOrganizationType: | |||||||||
| OtherLastName: | HUGHES | ||||||||
| OtherFirstName: | BRIDGET | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708586655 | ||||||||
| FaxNumber: | 2708584607 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 WILDCAT LN | ||||||||
| Address2: | |||||||||
| City: | BARDSTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400049076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444350900 | ||||||||
| FaxNumber: | 8884235216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2016 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3010746 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100437510 | 05 | KY | MEDICAID |