Provider Demographics
NPI:1104053891
Name:BLACKWELL, KELLIE MIRANDA SMITH (DO)
Entity type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:MIRANDA SMITH
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3889
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3889
Mailing Address - Country:US
Mailing Address - Phone:423-433-6625
Mailing Address - Fax:423-723-2669
Practice Address - Street 1:117 COOK ST
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-3203
Practice Address - Country:US
Practice Address - Phone:276-619-5052
Practice Address - Fax:276-619-5115
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5527207Q00000X
VA0102203141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAV V7187BMedicare PIN