Provider Demographics
NPI:1629550603
Name:BYRD, KELLIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:BYRD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74
Mailing Address - Street 2:
Mailing Address - City:MOSHEIM
Mailing Address - State:TN
Mailing Address - Zip Code:37818-0074
Mailing Address - Country:US
Mailing Address - Phone:423-278-6258
Mailing Address - Fax:
Practice Address - Street 1:1420 TUSCULUM BLVD
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4279
Practice Address - Country:US
Practice Address - Phone:423-787-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3695363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant