Provider Demographics
NPI:1104364496
Name:KIRBY, JUSTIN LANCE
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LANCE
Last Name:KIRBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 MCCALLIE AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3334
Mailing Address - Country:US
Mailing Address - Phone:423-698-2435
Mailing Address - Fax:
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:HOSPITALIST
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-5179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22286363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner