Provider Demographics
NPI:1063157857
Name:FRYAR, KELLYE (FNP)
Entity type:Individual
Prefix:
First Name:KELLYE
Middle Name:
Last Name:FRYAR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4662 E CIRCLE DR NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-4101
Mailing Address - Country:US
Mailing Address - Phone:423-790-7662
Mailing Address - Fax:423-790-7664
Practice Address - Street 1:463 1ST ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-1760
Practice Address - Country:US
Practice Address - Phone:423-790-7662
Practice Address - Fax:423-790-7664
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31553363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty