Provider Demographics
NPI:1851480099
Name:LUSK, KELLY PICKENS (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:PICKENS
Last Name:LUSK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 HIGHWAY 51 BY PASS WEST
Mailing Address - Street 2:SUITE A
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024
Mailing Address - Country:US
Mailing Address - Phone:731-286-8166
Mailing Address - Fax:731-286-1879
Practice Address - Street 1:1150 HIGHWAY 51 BY PASS WEST
Practice Address - Street 2:SUITE A
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-286-8166
Practice Address - Fax:731-286-1879
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000001300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3037162OtherBCBST
TN3037162OtherBCBST
TNU60639Medicare UPIN