Provider Demographics
NPI:1396900700
Name:MCCALLUM, KELLY M (APN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:MCCALLUM
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:2490 PARR AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2029
Mailing Address - Country:US
Mailing Address - Phone:731-286-8007
Mailing Address - Fax:731-286-8019
Practice Address - Street 1:2490 PARR AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2029
Practice Address - Country:US
Practice Address - Phone:731-286-8007
Practice Address - Fax:731-286-8019
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13555363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMG1805134OtherDEA