Basic Information
| Provider Information | |||||||||
| NPI: | 1629025812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEFFENDALL | ||||||||
| FirstName: | KELLIE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 719 THOMPSON LN STE 30330 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372044701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 THE VANDERBILT CLINIC | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372322598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159362000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 11020 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 4101930 | 01 | TN | BLUECARE | OTHER | 3634033 | 05 | TN | MEDICAID | 100047081 | 01 | TN | PHP TENNCARE | OTHER | P00243205 | 01 | TN | MEDICARE TRAVELERS | OTHER | 4101930 | 01 | TN | BLUE CROSS | OTHER |