Provider Demographics
NPI:1538204805
Name:ABRAHAM, ALYCE G (NP)
Entity type:Individual
Prefix:
First Name:ALYCE
Middle Name:G
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ALYCE
Other - Middle Name:
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2040 DOUGLASS BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6420 DUTCHMANS PKWY STE 190
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205
Practice Address - Country:US
Practice Address - Phone:502-588-7660
Practice Address - Fax:502-588-7893
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1088268363LW0102X
KY3002685363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health