Provider Demographics
NPI:1043996911
Name:PANTESS, MARY LEE (NP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LEE
Last Name:PANTESS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:LEE
Other - Last Name:ABOULHOSN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:817 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-2431
Mailing Address - Country:US
Mailing Address - Phone:502-259-8811
Mailing Address - Fax:
Practice Address - Street 1:3934 DIXIE HWY STE 420
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-5162
Practice Address - Country:US
Practice Address - Phone:502-200-1335
Practice Address - Fax:866-715-7614
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4005705363LF0000X
KY4004705363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health