Provider Demographics
NPI:1699018291
Name:PICKETT, KELLY B (NP-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:B
Last Name:PICKETT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S CEDAR LN
Mailing Address - Street 2:P.O. BOX 577
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-3502
Mailing Address - Country:US
Mailing Address - Phone:931-363-2511
Mailing Address - Fax:931-424-6109
Practice Address - Street 1:215 S CEDAR LN
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-3502
Practice Address - Country:US
Practice Address - Phone:931-363-2511
Practice Address - Fax:931-424-6109
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17426363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily