Provider Demographics
NPI:1477505717
Name:KELLEY, DEBRA JO (ND)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:JO
Last Name:KELLEY
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:TN
Mailing Address - Zip Code:38363-2308
Mailing Address - Country:US
Mailing Address - Phone:731-257-1248
Mailing Address - Fax:931-364-4660
Practice Address - Street 1:177 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:TN
Practice Address - Zip Code:38363-2308
Practice Address - Country:US
Practice Address - Phone:731-257-1248
Practice Address - Fax:931-364-4660
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11894363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q02824Medicare UPIN
TNY038WZMedicare PIN