1629071691 NPI number — KELLEY J SHARP NP

Table of content: KELLEY J SHARP NP (NPI 1629071691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629071691 NPI number — KELLEY J SHARP NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHARP
Provider First Name:
KELLEY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1629071691
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 CRESTVIEW PARK DR
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
DICKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37055-2855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-446-5121
Provider Business Mailing Address Fax Number:
615-446-1357

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 MATHIS DR
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
DICKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37055-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-441-4400
Provider Business Practice Location Address Fax Number:
615-446-1357
Provider Enumeration Date:
05/24/2005

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: 363LP0200X , with the licence number:  APN6660 , 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: 3158263 . This is a "BLUE CROSS BLUE SHIELD TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 500014527 . This is a "RAILROAD MEDICARE PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3902516 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4058108 . This is a "BLUE CROSS BLUE SHIELD TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".