Provider Demographics
NPI:1164583829
Name:HUDSON, KELLYE LADAWN (DNP, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:KELLYE
Middle Name:LADAWN
Last Name:HUDSON
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 FOREST CT
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-5078
Mailing Address - Country:US
Mailing Address - Phone:865-409-5695
Mailing Address - Fax:
Practice Address - Street 1:117 FOREST CT
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5078
Practice Address - Country:US
Practice Address - Phone:865-409-5695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000527106H00000X
TNRN0000162019163W00000X
TNAPN0000014218363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1506809Medicaid