Healthcare Provider Details

I. General information

NPI: 1912649120
Provider Name (Legal Business Name): KELLY DOUGLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3493 VETERANS DR N STE C
HUNTINGDON TN
38344-6230
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 731-986-2933
  • Fax: 731-986-2938
Mailing address:
  • Phone: 901-226-4003
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5629
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: