Healthcare Provider Details

I. General information

NPI: 1548104896
Provider Name (Legal Business Name): KELLI DENISE MINGA OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 ELIZABETHTON WAY
CLINTON TN
37716-4032
US

IV. Provider business mailing address

117 ELIZABETHTON WAY
CLINTON TN
37716-4032
US

V. Phone/Fax

Practice location:
  • Phone: 865-314-0005
  • Fax: 865-332-1900
Mailing address:
  • Phone: 865-314-0005
  • Fax: 865-332-1900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2110
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: