Provider Demographics
NPI:1285225300
Name:WALLACE, KELSEY SPILLER
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:SPILLER
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 SUBURBAN RD STE D102
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-5581
Mailing Address - Country:US
Mailing Address - Phone:865-424-7334
Mailing Address - Fax:865-263-8469
Practice Address - Street 1:103 SUBURBAN RD STE D102
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-5581
Practice Address - Country:US
Practice Address - Phone:865-424-7334
Practice Address - Fax:865-263-8469
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27966363LP0808X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health