Basic Information
| Provider Information | |||||||||
| NPI: | 1861784555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEHER | ||||||||
| FirstName: | SONJA | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOULWARE | ||||||||
| OtherFirstName: | SONJA | ||||||||
| OtherMiddleName: | GRACE LOUISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 975 E. THIRD STREET | ||||||||
| Address2: | ATTN: PROVIDER EMROLLMENT | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069379292 | ||||||||
| FaxNumber: | 7069377207 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 ERLANGER SOUTH DRIVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | RINGGOLD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069379292 | ||||||||
| FaxNumber: | 7069377207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2011 | ||||||||
| LastUpdateDate: | 11/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 072047 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 16874 | 01 | FL | TRAINING LICENSE | OTHER |