Provider Demographics
NPI:1821115676
Name:HARE, KELLY M (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:HARE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 PAVILION DR
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4641
Mailing Address - Country:US
Mailing Address - Phone:423-857-7650
Mailing Address - Fax:423-857-7655
Practice Address - Street 1:2205 PAVILION DR
Practice Address - Street 2:SUITE 201B
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4641
Practice Address - Country:US
Practice Address - Phone:423-857-7650
Practice Address - Fax:423-857-7655
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12652363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100023580Medicaid
TNP01662016OtherRR MEDICARE
TNQ016582Medicaid
VAV V3871AMedicare PIN
TNP01662016OtherRR MEDICARE
GAP00657039Medicare PIN
TN103I503179Medicare PIN
TN103I507508Medicare PIN
TN103G477120Medicare PIN
KY7100023580Medicaid
VA017058P50Medicare PIN
VAV V3871BMedicare PIN
TN103I502818Medicare PIN
TNP00657039Medicare PIN