Provider Demographics
NPI:1285235648
Name:KILLETT, SOPHIA GRACE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:GRACE
Last Name:KILLETT
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1852
Mailing Address - Country:US
Mailing Address - Phone:629-255-3486
Mailing Address - Fax:
Practice Address - Street 1:1622 WESTGATE CIR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-8019
Practice Address - Country:US
Practice Address - Phone:629-255-2277
Practice Address - Fax:629-255-4258
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4286363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4286OtherPA LICENSE
TNQ076744Medicaid