Provider Demographics
NPI:1093270241
Name:KELLEY, BETHANY JORDAN
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:JORDAN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:JORDAN
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5383 CHICKASAW RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-1742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7945 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1762
Practice Address - Country:US
Practice Address - Phone:901-683-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily