Healthcare Provider Details

I. General information

NPI: 1396862512
Provider Name (Legal Business Name): KRISTINA M KEGLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 PEACHTREE RD NW 5TH FLOOR, 77 BUILDING
ATLANTA GA
30309-1281
US

IV. Provider business mailing address

PO BOX 102321
ATLANTA GA
30368-2321
US

V. Phone/Fax

Practice location:
  • Phone: 404-605-2055
  • Fax: 404-609-6635
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number005001
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: