Provider Demographics
NPI:1033640404
Name:STAFFORD, KELSIE
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N MURRAY ST
Mailing Address - Street 2:
Mailing Address - City:GAINESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38562-9313
Mailing Address - Country:US
Mailing Address - Phone:931-268-0218
Mailing Address - Fax:
Practice Address - Street 1:600 N MURRAY ST
Practice Address - Street 2:
Practice Address - City:GAINESBORO
Practice Address - State:TN
Practice Address - Zip Code:38562-9313
Practice Address - Country:US
Practice Address - Phone:931-268-0218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN 0000207309163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse