Basic Information
| Provider Information | |||||||||
| NPI: | 1912932039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PITTMAN | ||||||||
| FirstName: | NICCI | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3085 LAKECREST CIR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405131707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592588600 | ||||||||
| FaxNumber: | 8592588610 | ||||||||
| Practice Location | |||||||||
| Address1: | 3085 LAKECREST CIR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405131707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592588600 | ||||||||
| FaxNumber: | 8592588610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
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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 | 207Q00000X | 31824 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080140770 | 01 | KY | RR MEDICARE PIN | OTHER | 4000501 | 01 | KY | MEDICARE LAB GROUP | OTHER | 64877566 | 05 | KY | MEDICAID | CB5773 | 01 | KY | RR MEDICARE GROUP | OTHER | 37903705 | 01 | KY | MEDICAID LAB GROUP | OTHER |