1134604226 NPI number — KAYLEE CHRISTENSEN MMS, PA-C

Table of content: KAYLEE CHRISTENSEN MMS, PA-C (NPI 1134604226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134604226 NPI number — KAYLEE CHRISTENSEN MMS, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHRISTENSEN
Provider First Name:
KAYLEE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MMS, PA-C
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:
1134604226
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
511 SHADOW PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-5334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-719-5814
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
975 E 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-778-5179
Provider Business Practice Location Address Fax Number:
423-778-2108
Provider Enumeration Date:
09/25/2018

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: 363AM0700X , with the licence number:  3734 , 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: 3734 . This is a "TENNESSEE MEDICAL LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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