Provider Demographics
NPI:1134532567
Name:KELLY, HEIDI LEA (FNP-BC, MSN, MPH, RN)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:LEA
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP-BC, MSN, MPH, RN
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:LEA
Other - Last Name:SWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-5701
Mailing Address - Country:US
Mailing Address - Phone:423-760-4000
Mailing Address - Fax:
Practice Address - Street 1:1300 E 23RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-5701
Practice Address - Country:US
Practice Address - Phone:423-760-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR17016400163W00000X
VA0001256235163W00000X
NY671570163W00000X
TN233514163W00000X
TN24989363LF0000X
VA0024172403363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse