Provider Demographics
NPI:1942765615
Name:GREENLEE, KRISTIE VAUGHN (NP)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:VAUGHN
Last Name:GREENLEE
Suffix:
Gender:F
Credentials:NP
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 8
Mailing Address - Street 2:
Mailing Address - City:BULLS GAP
Mailing Address - State:TN
Mailing Address - Zip Code:37711-0008
Mailing Address - Country:US
Mailing Address - Phone:423-393-4052
Mailing Address - Fax:
Practice Address - Street 1:275 HIGHWAY 11 E
Practice Address - Street 2:
Practice Address - City:BULLS GAP
Practice Address - State:TN
Practice Address - Zip Code:37711-3417
Practice Address - Country:US
Practice Address - Phone:423-393-4052
Practice Address - Fax:423-933-2915
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN217411363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ059118Medicaid