Healthcare Provider Details

I. General information

NPI: 1346565629
Provider Name (Legal Business Name): KASEY LAX ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2010
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W MARKET STREET
BOLIVAR TN
38008-2519
US

IV. Provider business mailing address

PO BOX 400
JACKSON TN
38302-0400
US

V. Phone/Fax

Practice location:
  • Phone: 731-658-2885
  • Fax: 731-658-2886
Mailing address:
  • Phone: 731-425-5752
  • Fax: 731-422-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number139704
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14931
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: