Provider Demographics
NPI:1265926208
Name:KELLEY, SAMANTHA CAITLIN
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:CAITLIN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523A W HOLLIS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3443 DICKERSON PIKE STE 680
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37207
Practice Address - Country:US
Practice Address - Phone:615-865-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN198215163WE0003X
TN24559363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100550900Medicaid
TNQ044832Medicaid