Provider Demographics
NPI:1144971409
Name:O'DANIEL, KATELYNN S (APRN)
Entity type:Individual
Prefix:
First Name:KATELYNN
Middle Name:S
Last Name:O'DANIEL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-559-9378
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:2410 RING RD STE 500
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7991
Practice Address - Country:US
Practice Address - Phone:502-559-3636
Practice Address - Fax:270-769-0931
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3017238363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300062101Medicaid