Basic Information
| Provider Information | |||||||||
| NPI: | 1952357774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDLEY | ||||||||
| FirstName: | INGRID | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 CRANES ROOST CT | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427013650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707652605 | ||||||||
| FaxNumber: | 2707661222 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 DREXLER CIR | ||||||||
| Address2: | STE 1 | ||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427017843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705062730 | ||||||||
| FaxNumber: | 2709000704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 01/15/2016 | ||||||||
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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 | 363LP0808X | 2641S | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 11386453 | 01 | CAQH | OTHER | 000000174962 | 01 | KY | ANTHEM | OTHER | 30605018 | 05 | KY | MEDICAID | 341184 | 01 | KY | TRICARE | OTHER |