Provider Demographics
NPI:1326437120
Name:PETERSON, KELLY LEIGH (PNP-AC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LEIGH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 DEMONBREUN ST
Mailing Address - Street 2:APT 1012
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-3182
Mailing Address - Country:US
Mailing Address - Phone:406-531-2943
Mailing Address - Fax:
Practice Address - Street 1:2200 CHILDRENS WAY MONROE CARELL JR
Practice Address - Street 2:DOCTOR'S OFFICE TOWER, 7TH FLOOR, SUITE 7100
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0001
Practice Address - Country:US
Practice Address - Phone:615-936-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19462363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics