Provider Demographics
NPI:1316773419
Name:TREADWAY, KELLY TAYLOR (FNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:TAYLOR
Last Name:TREADWAY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:TAYLOR
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:549 COLLINWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-4871
Mailing Address - Country:US
Mailing Address - Phone:931-619-3336
Mailing Address - Fax:
Practice Address - Street 1:549 COLLINWOOD DR
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-4871
Practice Address - Country:US
Practice Address - Phone:931-619-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-13
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37314363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily