Provider Demographics
NPI:1447859053
Name:KELLY, WILLIE FAYE (NP)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:FAYE
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4315
Mailing Address - Country:US
Mailing Address - Phone:901-567-3554
Mailing Address - Fax:901-567-3559
Practice Address - Street 1:1331 UNION AVE STE 1226
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7509
Practice Address - Country:US
Practice Address - Phone:901-235-1722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28400363LP0808X
TNPENDING363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health