Healthcare Provider Details

I. General information

NPI: 1902235146
Provider Name (Legal Business Name): KELLY NICOLE DAVIS DPT, ATC, COMT, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 CHATEAUGAY LN NE
ATLANTA GA
30342-3404
US

IV. Provider business mailing address

540 CHATEAUGAY LN NE
ATLANTA GA
30342-3404
US

V. Phone/Fax

Practice location:
  • Phone: 610-256-2860
  • Fax:
Mailing address:
  • Phone: 610-256-2860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000006843
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT017188
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number299323
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: