Healthcare Provider Details

I. General information

NPI: 1265926208
Provider Name (Legal Business Name): SAMANTHA CAITLIN KELLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3443 DICKERSON PIKE STE 680
NASHVILLE TN
37207
US

IV. Provider business mailing address

523A W HOLLIS CHAPEL RD
PORTLAND TN
37148-5348
US

V. Phone/Fax

Practice location:
  • Phone: 615-865-3322
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number24559
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number198215
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: