Basic Information
| Provider Information | |||||||||
| NPI: | 1366102675 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALES | ||||||||
| FirstName: | KARA | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 454 POPLAR GROVE RD | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376645541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237828049 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2103 FOREST DR STE 5 | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376158423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237943142 | ||||||||
| FaxNumber: | 4237943184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2021 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 30732 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | Q072773 | 05 | TN | MEDICAID |