Provider Demographics
NPI:1902875644
Name:BRANSTETTER, MARY LAURETTA (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LAURETTA
Last Name:BRANSTETTER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-864-1472
Mailing Address - Fax:270-864-1693
Practice Address - Street 1:301 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3487
Practice Address - Country:US
Practice Address - Phone:270-651-9696
Practice Address - Fax:270-651-0385
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002615363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78004363Medicaid
KYK114320Medicare PIN
KYS74937Medicare UPIN