Provider Demographics
NPI:1154432003
Name:HARNESS, KELLY E (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:HARNESS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:E
Other - Last Name:VAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-952-2111
Mailing Address - Fax:423-282-1657
Practice Address - Street 1:344 OVERLOOK DR STE 200
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-3436
Practice Address - Country:US
Practice Address - Phone:276-883-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2025-01-16
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-02-15
Provider Licenses
StateLicense IDTaxonomies
MO153499363LF0000X
TN27841363LF0000X
VA0024180875363LF0000X
NC5010643363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425076205Medicaid
Q06855Medicare UPIN
818852943Medicare PIN
MO425076205Medicaid