Provider Demographics
NPI:1891225116
Name:ETGHAYI, KELLEE A (APRN)
Entity Type:Individual
Prefix:
First Name:KELLEE
Middle Name:A
Last Name:ETGHAYI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-425-5752
Mailing Address - Fax:731-425-5783
Practice Address - Street 1:145 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3019
Practice Address - Country:US
Practice Address - Phone:731-422-0213
Practice Address - Fax:731-660-8453
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23140363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner