Healthcare Provider Details

I. General information

NPI: 1477378891
Provider Name (Legal Business Name): KELLIE DIANNE AZOR AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 WHITE OAK RD STE 400
DAYTON TN
37321-2238
US

IV. Provider business mailing address

4922 MCDONALD RD
MC DONALD TN
37353-4057
US

V. Phone/Fax

Practice location:
  • Phone: 423-778-5661
  • Fax:
Mailing address:
  • Phone: 615-812-1687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number37247
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number37247
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: