Basic Information
Provider Information | |||||||||
NPI: | 1609364785 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STAPLETON | ||||||||
FirstName: | KELSEY | ||||||||
MiddleName: | ELISABETH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRIFFITTS | ||||||||
OtherFirstName: | KELSEY | ||||||||
OtherMiddleName: | ELISABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9 | ||||||||
Address2: |   | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376620009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238572093 | ||||||||
FaxNumber: | 4233903340 | ||||||||
Practice Location | |||||||||
Address1: | 631 CAMPUS DR | ||||||||
Address2: |   | ||||||||
City: | ABINGDON | ||||||||
State: | VA | ||||||||
PostalCode: | 242109700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2766763870 | ||||||||
FaxNumber: | 2766288927 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2018 | ||||||||
LastUpdateDate: | 10/31/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/31/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3586 | TN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 0110006122 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.