Provider Demographics
NPI:1447662077
Name:NETTLETON, LINDY
Entity type:Individual
Prefix:
First Name:LINDY
Middle Name:
Last Name:NETTLETON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7723
Mailing Address - Fax:615-920-8775
Practice Address - Street 1:645 INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1704
Practice Address - Country:US
Practice Address - Phone:606-474-0669
Practice Address - Fax:606-474-0376
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36691207Q00000X
390200000X
KY04270207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPENDNGMedicaid