Healthcare Provider Details

I. General information

NPI: 1730226804
Provider Name (Legal Business Name): KELLY MARIE BADURA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8970 WINCHESTER RD
MEMPHIS TN
38125
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 315
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 901-794-5806
  • Fax: 901-794-7922
Mailing address:
  • Phone:
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1174
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: