Provider Demographics
NPI:1689998403
Name:THOMPSON, KELLY LAUREN (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LAUREN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LAUREN
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:160 FOREST LN N
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-6452
Mailing Address - Country:US
Mailing Address - Phone:423-483-1617
Mailing Address - Fax:
Practice Address - Street 1:111 W STONE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-6027
Practice Address - Country:US
Practice Address - Phone:423-224-3701
Practice Address - Fax:423-224-3709
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14871363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1689998403Medicaid
TN1518455Medicaid
VA1689998403Medicaid
TN103I509990Medicare PIN