Healthcare Provider Details

I. General information

NPI: 1831621952
Provider Name (Legal Business Name): KELLEY FUNDERBURG APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S GERMANTOWN RD
GERMANTOWN TN
38138-2205
US

IV. Provider business mailing address

1400 S GERMANTOWN RD
GERMANTOWN TN
38138-2205
US

V. Phone/Fax

Practice location:
  • Phone: 901-759-3100
  • Fax:
Mailing address:
  • Phone: 901-759-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22448
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: