Provider Demographics
NPI:1780989772
Name:STEPHENSON, KELLI DEAN (FNP-C)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:DEAN
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:DEAN
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:877 JEFFERSON AVENUE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:015-456-2869
Mailing Address - Fax:
Practice Address - Street 1:2500 PERES AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38108-1660
Practice Address - Country:US
Practice Address - Phone:901-515-5500
Practice Address - Fax:901-458-5591
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33371363L00000X, 367A00000X
OR201394741NP-PP363LF0000X
WAAP60494710363LF0000X
OR201800264NP-PP363LX0001X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology