1902100894 NPI number — KATHIE KELLUM RPH

Table of content: KATHIE KELLUM RPH (NPI 1902100894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902100894 NPI number — KATHIE KELLUM RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLUM
Provider First Name:
KATHIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1902100894
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
68 COUNTY ROAD 68
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOLDEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38847-7756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-454-7558
Provider Business Mailing Address Fax Number:
731-645-6001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
399 MULBERRY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELMER
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38375-2305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-645-6182
Provider Business Practice Location Address Fax Number:
731-645-6001
Provider Enumeration Date:
01/06/2011

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: 183500000X , with the licence number:  8385 , 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)