Provider Demographics
NPI:1508505983
Name:BLACKETT, KYLIE DANIELLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:KYLIE
Middle Name:DANIELLE
Last Name:BLACKETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 N MOUNT JULIET RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-3059
Mailing Address - Country:US
Mailing Address - Phone:615-975-9543
Mailing Address - Fax:
Practice Address - Street 1:3500 N MOUNT JULIET RD STE 201
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3059
Practice Address - Country:US
Practice Address - Phone:615-758-5672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31898207Q00000X
TN191152163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163W00000XNursing Service ProvidersRegistered Nurse