Provider Demographics
NPI:1992265003
Name:KELLY, SUSAN ELIZABETH (FNP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 CLIFFORD PRICE LOOP
Mailing Address - Street 2:
Mailing Address - City:MOORESBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37811-2337
Mailing Address - Country:US
Mailing Address - Phone:423-754-9648
Mailing Address - Fax:
Practice Address - Street 1:239 CLIFFORD PRICE LOOP
Practice Address - Street 2:
Practice Address - City:MOORESBURG
Practice Address - State:TN
Practice Address - Zip Code:37811-2337
Practice Address - Country:US
Practice Address - Phone:423-754-9648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-24
Last Update Date:2019-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPRN0000025532363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily