Provider Demographics
NPI:1437829314
Name:SHELTON, KAYLIE NICHOLE
Entity Type:Individual
Prefix:
First Name:KAYLIE
Middle Name:NICHOLE
Last Name:SHELTON
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 1:200 TECH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-2747
Mailing Address - Country:US
Mailing Address - Phone:865-637-9711
Mailing Address - Fax:
Practice Address - Street 1:6049 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1688
Practice Address - Country:US
Practice Address - Phone:423-266-6751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN171M00000X, 390200000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program