Healthcare Provider Details

I. General information

NPI: 1164275566
Provider Name (Legal Business Name): KALI RENEE RUTHERFORD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 S SIZER AVE STE A
JEFFERSON CTY TN
37760-2421
US

IV. Provider business mailing address

10200 GRAND CENTRAL AVE STE 220
OWINGS MILLS MD
21117-4366
US

V. Phone/Fax

Practice location:
  • Phone: 865-690-3811
  • Fax:
Mailing address:
  • Phone: 865-690-3811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5906
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: