Provider Demographics
NPI:1871277285
Name:KELLY, TINA (MSN, FNP-C)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:WILKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:MCCOY MEDICAL
Mailing Address - Street 2:1324 SOUTH HOME STREET
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261
Mailing Address - Country:US
Mailing Address - Phone:731-885-8881
Mailing Address - Fax:
Practice Address - Street 1:MCCOY MEDICAL
Practice Address - Street 2:1324 SOUTH HOME STREET
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261
Practice Address - Country:US
Practice Address - Phone:731-885-8881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34204363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily