Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 110067 | KY |
NPI | 1225619851 |
---|---|
Provider Name | Dianna Sorensen |
First Address | Lexington, KY 40504-3674 |
Second Address | Lexington, KY 40504-3674 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/04/2021 |
Last Update Date | 15/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003908849 | (05) | KY |