Healthcare Provider Details

I. General information

NPI: 1023498045
Provider Name (Legal Business Name): KELLY NICOLE SLY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY NICOLE DUCKWORTH

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3444 PLAZA AVE
MEMPHIS TN
38111-4614
US

IV. Provider business mailing address

2620 ELM HILL PIKE
NASHVILLE TN
37214-3108
US

V. Phone/Fax

Practice location:
  • Phone: 901-730-4204
  • Fax:
Mailing address:
  • Phone: 615-425-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA004410
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: