Provider Demographics
NPI:1912649120
Name:DOUGLAS, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DOUGLAS
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 1:211 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-3124
Mailing Address - Country:US
Mailing Address - Phone:731-415-4052
Mailing Address - Fax:
Practice Address - Street 1:3493 VETERANS DR N STE C
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-6230
Practice Address - Country:US
Practice Address - Phone:731-986-2933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-08
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN5629363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program