Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 21304 | TN |
NPI | 1003268053 |
---|---|
Provider Name | Mrs. Kellie R. Gaby |
First Address | Maryville, TN 37801-4703 |
Second Address | Alcoa, TN 37701-2422 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2016 |
Last Update Date | 10/05/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Q022882 | (05) | TN |