Healthcare Provider Details

I. General information

NPI: 1831161090
Provider Name (Legal Business Name): ELIZABETH ANN KELLY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 RE JENNINGS AVE SE P.O. DRAWER R
ARLINGTON GA
39813-8725
US

IV. Provider business mailing address

55 RE JENNINGS AVE SE P.O. DRAWER R
ARLINGTON GA
39813-8722
US

V. Phone/Fax

Practice location:
  • Phone: 229-725-4251
  • Fax: 229-725-2212
Mailing address:
  • Phone: 229-725-4272
  • Fax: 229-725-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN050989
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN050989
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: