Provider Demographics
NPI:1700126547
Name:DAWSON, KELLYE TAYLOR
Entity Type:Individual
Prefix:DR
First Name:KELLYE
Middle Name:TAYLOR
Last Name:DAWSON
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 1:67 MADISON AVE
Mailing Address - Street 2:APT 407
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 MADISON AVE
Practice Address - Street 2:APT 407
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2147
Practice Address - Country:US
Practice Address - Phone:615-604-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000036527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist