Provider Demographics
NPI:1669956009
Name:JOHNSON, KELLYE S (CRNA)
Entity type:Individual
Prefix:
First Name:KELLYE
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLYE
Other - Middle Name:R
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 51947
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-1947
Mailing Address - Country:US
Mailing Address - Phone:865-588-0880
Mailing Address - Fax:865-584-3111
Practice Address - Street 1:1924 ALCOA HWY # U109
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1511
Practice Address - Country:US
Practice Address - Phone:865-305-9220
Practice Address - Fax:865-637-5518
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24984367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered