Basic Information
| Provider Information | |||||||||
| NPI: | 1710940820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILES | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 465 N PARK 40 BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379233615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657694545 | ||||||||
| FaxNumber: | 8657694501 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 N PARK 40 BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379233615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653575088 | ||||||||
| FaxNumber: | 8656913617 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5159 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3645785 | 05 | TN | MEDICAID |