Provider Demographics
NPI:1023057650
Name:AMYX, KELLY (MSOT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:AMYX
Suffix:
Gender:F
Credentials:MSOT
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 681478
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-1478
Mailing Address - Country:US
Mailing Address - Phone:866-800-9147
Mailing Address - Fax:615-591-6601
Practice Address - Street 1:121 VILLAGE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1418
Practice Address - Country:US
Practice Address - Phone:615-323-7575
Practice Address - Fax:615-323-0677
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2969225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4220815OtherBCBS OF TENNESSEE
TN3655053Medicare PIN
TN446631Medicare ID - Type UnspecifiedGROUP