Provider Demographics
NPI:1033686787
Name:SAN MIGUEL, MARY JUDE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JUDE
Last Name:SAN MIGUEL
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 1:406 BLANKENBAKER PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1881
Mailing Address - Country:US
Mailing Address - Phone:502-434-5176
Mailing Address - Fax:
Practice Address - Street 1:406 BLANKENBAKER PKWY STE A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1881
Practice Address - Country:US
Practice Address - Phone:502-434-5176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001299A237700000X
KY290047237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist