Provider Demographics
NPI:1215762349
Name:BOTTS, KELLIE (RN, CPM)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:BOTTS
Suffix:
Gender:F
Credentials:RN, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-0088
Mailing Address - Country:US
Mailing Address - Phone:865-214-7311
Mailing Address - Fax:865-378-5026
Practice Address - Street 1:3239 SHROPSHIRE BLVD UNIT 88
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-8405
Practice Address - Country:US
Practice Address - Phone:865-214-7311
Practice Address - Fax:865-378-5026
Is Sole Proprietor?:No
Enumeration Date:2024-09-06
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN148176B00000X
TN208325163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse