Healthcare Provider Details

I. General information

NPI: 1760386197
Provider Name (Legal Business Name): BONITA MARIE KELM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 KASEN LN
ETHRIDGE TN
38456-3001
US

IV. Provider business mailing address

170 KASEN LN
ETHRIDGE TN
38456-3001
US

V. Phone/Fax

Practice location:
  • Phone: 731-458-7046
  • Fax: 731-458-7046
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number271296
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: