Provider Demographics
NPI:1790408961
Name:TELLEZ, JACQUELINE KATHY
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KATHY
Last Name:TELLEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 BRISTOL HWY
Mailing Address - Street 2:
Mailing Address - City:WATAUGA
Mailing Address - State:TN
Mailing Address - Zip Code:37694-3198
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1834 BRISTOL HWY
Practice Address - Street 2:
Practice Address - City:WATAUGA
Practice Address - State:TN
Practice Address - Zip Code:37694-3198
Practice Address - Country:US
Practice Address - Phone:423-833-6539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000031726363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily