Provider Demographics
NPI:1578295333
Name:HUDSON, KEELY GENE-ELAINE
Entity type:Individual
Prefix:
First Name:KEELY
Middle Name:GENE-ELAINE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:GENE-ELAINE
Other - Last Name:HAWKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6401 POPLAR AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4840
Mailing Address - Country:US
Mailing Address - Phone:901-685-2696
Mailing Address - Fax:
Practice Address - Street 1:6401 POPLAR AVE STE 100
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4840
Practice Address - Country:US
Practice Address - Phone:901-685-2696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant