1447859053 NPI number — WILLIE FAYE KELLY NP

Table of content: WILLIE FAYE KELLY NP (NPI 1447859053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447859053 NPI number — WILLIE FAYE KELLY NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
WILLIE
Provider Middle Name:
FAYE
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:
1447859053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2220 UNION AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38104-4315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-567-3554
Provider Business Mailing Address Fax Number:
901-567-3559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1331 UNION AVE STE 1226
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38104-7509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-235-1722
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2020

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: 363LP0808X , with the licence number:  28400 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: PENDING , 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)