Basic Information
| Provider Information | |||||||||
| NPI: | 1093270241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | JORDAN | ||||||||
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| OtherLastName: | KELLEY | ||||||||
| OtherFirstName: | BETHANY | ||||||||
| OtherMiddleName: | JORDAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5383 CHICKASAW RD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381201742 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7945 WOLF RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381381762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016830055 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2019 | ||||||||
| LastUpdateDate: | 02/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 25460 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.