Provider Demographics
NPI:1013799766
Name:KENNERLY, TIFFANY LEATRICE (RN)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:LEATRICE
Last Name:KENNERLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 FROST ST
Mailing Address - Street 2:
Mailing Address - City:DECHERD
Mailing Address - State:TN
Mailing Address - Zip Code:37324-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 RIVERFRONT PKWY STE 209
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-3312
Practice Address - Country:US
Practice Address - Phone:423-634-3124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN236782163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse