Healthcare Provider Details

I. General information

NPI: 1164927489
Provider Name (Legal Business Name): KELLY ANN NORMAN CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 SHARP AND PERKINS RD
JACKSBORO TN
37757-2507
US

IV. Provider business mailing address

162 SHARP AND PERKINS RD
JACKSBORO TN
37757-2507
US

V. Phone/Fax

Practice location:
  • Phone: 423-562-8351
  • Fax:
Mailing address:
  • Phone: 423-562-8351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberJ4E9Q6Z4
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: