=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154398105
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLEY VINCENT JEFFERSON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2006
-----------------------------------------------------
Last Update Date | 01/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1224 TROTWOOD AVE
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38401-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-359-4506
-----------------------------------------------------
Fax | 931-490-7043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2717 EAST OAKLAND AVENUE
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37601-1843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-926-2358
-----------------------------------------------------
Fax | 423-926-2680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD37199
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 37199
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD37199
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------