Provider Demographics
NPI:1477378891
Name:AZOR, KELLIE DIANNE (AGNP-C)
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:DIANNE
Last Name:AZOR
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4922 MCDONALD RD
Mailing Address - Street 2:
Mailing Address - City:MC DONALD
Mailing Address - State:TN
Mailing Address - Zip Code:37353-4057
Mailing Address - Country:US
Mailing Address - Phone:615-812-1687
Mailing Address - Fax:
Practice Address - Street 1:195 WHITE OAK RD STE 400
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-2238
Practice Address - Country:US
Practice Address - Phone:423-778-5661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37247363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology