Healthcare Provider Details

I. General information

NPI: 1669726386
Provider Name (Legal Business Name): KELLIE O'CONNELL SALLIS ACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2012
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 W BADDOUR PKWY
LEBANON TN
37087-3061
US

IV. Provider business mailing address

PO BOX 1165
LEBANON TN
37088-1165
US

V. Phone/Fax

Practice location:
  • Phone: 615-257-0900
  • Fax: 615-443-1444
Mailing address:
  • Phone: 615-257-0900
  • Fax: 615-443-1444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number17137
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number17137
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: