Basic Information
| Provider Information | |||||||||
| NPI: | 1679047146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUMLEY | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETERS | ||||||||
| OtherFirstName: | KELLEY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2020 EXETER RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381383945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017473630 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 27 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314241001 | ||||||||
| FaxNumber: | 7314260344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2019 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 205390 | TN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 25362 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 25362 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.