Provider Demographics
NPI:1649479460
Name:GRANESE, JACQUELINE (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GRANESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:270-843-3376
Practice Address - Street 1:1065 ASHLEY ST STE 200
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-3401
Practice Address - Country:US
Practice Address - Phone:270-843-3376
Practice Address - Fax:270-780-0496
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42560207ND0900X, 207ND0900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100072860Medicaid
KY7100072860Medicaid
KYP00711077OtherRAILROAD MEDICARE
KY7100072860Medicaid