Healthcare Provider Details

I. General information

NPI: 1700160843
Provider Name (Legal Business Name): KELLY MARYANN PORTER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY MARYANN BACHELOR

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SKYLINE DR
JACKSON TN
38301-3923
US

IV. Provider business mailing address

PO BOX 3788
JACKSON TN
38303-3788
US

V. Phone/Fax

Practice location:
  • Phone: 731-541-5000
  • Fax: 731-660-8739
Mailing address:
  • Phone: 731-660-8730
  • Fax: 731-660-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2339
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: