Provider Demographics
NPI:1548582588
Name:IDLER, KELLY K (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:IDLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:K
Other - Last Name:GENTRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3103 BUSINESS PARK CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3676
Mailing Address - Country:US
Mailing Address - Phone:615-851-7865
Mailing Address - Fax:615-851-7853
Practice Address - Street 1:3103 BUSINESS PARK CIR STE 100
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-3676
Practice Address - Country:US
Practice Address - Phone:615-851-7865
Practice Address - Fax:615-851-7853
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN6529363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1517377Medicaid