Provider Demographics
NPI:1134714090
Name:DEVAULT, KELSEY B (NP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:B
Last Name:DEVAULT
Suffix:
Gender:
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 632476
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2476
Mailing Address - Country:US
Mailing Address - Phone:423-794-5988
Mailing Address - Fax:423-232-8583
Practice Address - Street 1:121 BOONE RIDGE DR STE 1004
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4993
Practice Address - Country:US
Practice Address - Phone:423-794-5988
Practice Address - Fax:423-232-8583
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29146363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner