Provider Demographics
NPI:1003923962
Name:BOGGAN, KELLY PATRICE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:PATRICE
Last Name:BOGGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:PATRICE
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901-5004
Mailing Address - Country:US
Mailing Address - Phone:865-541-8895
Mailing Address - Fax:865-633-4808
Practice Address - Street 1:1400 DUTCH VALLEY DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-1424
Practice Address - Country:US
Practice Address - Phone:865-689-1122
Practice Address - Fax:865-689-2923
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24699208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3077452Medicaid
TN4148578OtherBCBS
TN4148578OtherBCBS