Basic Information
| Provider Information | |||||||||
| NPI: | 1871526194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYDEN | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | DUNCAN | ||||||||
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| Credential: | AOCNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | SUITE 6A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234087220 | ||||||||
| FaxNumber: | 4234087405 | ||||||||
| Practice Location | |||||||||
| Address1: | 671 HIGHWAY 58 E | ||||||||
| Address2: | |||||||||
| City: | NORTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242733007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766795874 | ||||||||
| FaxNumber: | 2766796912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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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 | 363L00000X | APN0000006314 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 0024166936 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100062220 | 05 | KY | MEDICAID |