Provider Demographics
NPI:1871758417
Name:MATHERLY, LAURA ROSS (ARNP)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ROSS
Last Name:MATHERLY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7818
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:4359 NEW SHEPHERDSVILLE RD
Practice Address - Street 2:SUITE 255
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-8000
Practice Address - Country:US
Practice Address - Phone:502-350-5800
Practice Address - Fax:502-350-5820
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY5616P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100100500 (KOHMG)Medicaid
KYK116211 (KOHMG)Medicare PIN