Healthcare Provider Details

I. General information

NPI: 1225145865
Provider Name (Legal Business Name): KELLIE LAWRENCE HENDERSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE MICHELE LAWRENCE

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 TOMBRAS AVE
EAST RIDGE TN
37412-2720
US

IV. Provider business mailing address

1508 TOMBRAS AVE
EAST RIDGE TN
37412-2720
US

V. Phone/Fax

Practice location:
  • Phone: 423-867-4969
  • Fax: 423-867-4971
Mailing address:
  • Phone: 423-867-4969
  • Fax: 423-867-4971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA0000001098
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: