Provider Demographics
NPI:1922450758
Name:FREDERICKS, KELSEY HORNER (NP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:HORNER
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:ELIZABETH
Other - Last Name:HORNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 15010
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901-5010
Mailing Address - Country:US
Mailing Address - Phone:865-541-8187
Mailing Address - Fax:865-541-8286
Practice Address - Street 1:2018 CLINCH AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916
Practice Address - Country:US
Practice Address - Phone:865-541-8266
Practice Address - Fax:865-541-8553
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20848363LP0200X, 363LA2100X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ049909Medicaid