Healthcare Provider Details

I. General information

NPI: 1184471377
Provider Name (Legal Business Name): KELLIE ELISE WYDRINSKI PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2024
Last Update Date: 07/12/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FERRY RD STE 820
ATLANTA GA
30342-1608
US

IV. Provider business mailing address

980 JOHNSON FERRY RD STE 820
ATLANTA GA
30342-1608
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-9307
  • Fax: 404-252-5839
Mailing address:
  • Phone: 404-252-9307
  • Fax: 404-252-5839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12383
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: