Provider Demographics
NPI:1043557473
Name:COMPLETE FAMILY CARE PRACTITIONERS
Entity type:Organization
Organization Name:COMPLETE FAMILY CARE PRACTITIONERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:270-422-2200
Mailing Address - Street 1:1065 OLD EKRON RD
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-1735
Mailing Address - Country:US
Mailing Address - Phone:270-422-2200
Mailing Address - Fax:
Practice Address - Street 1:1065 OLD EKRON RD
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1735
Practice Address - Country:US
Practice Address - Phone:270-422-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-04
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100234400Medicaid
KY7100234400Medicaid
KYK078000Medicare PIN