Provider Demographics
NPI:1871526194
Name:MAYDEN, KELLEY DUNCAN (AOCNP)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:DUNCAN
Last Name:MAYDEN
Suffix:
Gender:F
Credentials:AOCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:671 HIGHWAY 58 E
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-3007
Practice Address - Country:US
Practice Address - Phone:276-679-5874
Practice Address - Fax:276-679-6912
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000006314363L00000X
VA0024166936363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100062220Medicaid
VAMC11993Medicare PIN
KY7100062220Medicaid
TNP27474Medicare UPIN
TN103I508327Medicare PIN