Provider Demographics
NPI:1538737606
Name:JOENBORG, NICOLINE
Entity type:Individual
Prefix:
First Name:NICOLINE
Middle Name:
Last Name:JOENBORG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MEDICAL VILLAGE DR STE 132
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5401
Practice Address - Country:US
Practice Address - Phone:859-578-5880
Practice Address - Fax:859-578-5881
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
KYTC119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant