Healthcare Provider Details

I. General information

NPI: 1609838671
Provider Name (Legal Business Name): KELLI JO BRUMMER MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLI JO NOBLE

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 ADESSA PKWY STE A140
LENOIR CITY TN
37771-6720
US

IV. Provider business mailing address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

V. Phone/Fax

Practice location:
  • Phone: 865-988-7610
  • Fax: 865-988-6636
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-238-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7158
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: