Provider Demographics
NPI:1669726386
Name:SALLIS, KELLIE O'CONNELL (ACNP-BC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:O'CONNELL
Last Name:SALLIS
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1165
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37088-1165
Mailing Address - Country:US
Mailing Address - Phone:615-257-0900
Mailing Address - Fax:615-443-1444
Practice Address - Street 1:1423 W BADDOUR PKWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3061
Practice Address - Country:US
Practice Address - Phone:615-257-0900
Practice Address - Fax:615-443-1444
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17137363LA2100X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine