Provider Demographics
NPI:1497790554
Name:WILLIMON, KELLI (FNP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:WILLIMON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5141 VIRGINIA WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7572
Mailing Address - Country:US
Mailing Address - Phone:615-661-5680
Mailing Address - Fax:
Practice Address - Street 1:5141 VIRGINIA WAY
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7572
Practice Address - Country:US
Practice Address - Phone:615-661-5680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2952363LF0000X
TNAPN0000017752363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN17752OtherFNP LICENSE
SC2952OtherFNP LICENSE
SC1497790554OtherNPI -PERSONAL-
TN195624OtherRN LICENSE