1265926208 NPI number — SAMANTHA CAITLIN KELLEY

Table of content: SAMANTHA CAITLIN KELLEY (NPI 1265926208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265926208 NPI number — SAMANTHA CAITLIN KELLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
SAMANTHA
Provider Middle Name:
CAITLIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265926208
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
523A W HOLLIS CHAPEL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37148-5348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3443 DICKERSON PIKE STE 680
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-865-3322
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/21/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WE0003X , with the licence number:  198215 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: 24559 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100550900 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q044832 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".