Healthcare Provider Details

I. General information

NPI: 1730502733
Provider Name (Legal Business Name): KELLEY RENEE LOGAN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLEY RENEE BASS NP

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

573 CARTHAGE BYP
CARTHAGE TN
37030-1573
US

IV. Provider business mailing address

427 WATERBROOK DR
MOUNT JULIET TN
37122-4252
US

V. Phone/Fax

Practice location:
  • Phone: 615-486-6178
  • Fax: 615-486-6179
Mailing address:
  • Phone: 615-972-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17924
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: