Healthcare Provider Details

I. General information

NPI: 1417163916
Provider Name (Legal Business Name): KELLY K HUDSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 IVAN ALLEN JR. BOULEVARD
ATLANTA GA
30313
US

IV. Provider business mailing address

440 SUMMERFIELD DRIVE
ALPHARETTA GA
30022
US

V. Phone/Fax

Practice location:
  • Phone: 404-523-6571
  • Fax: 404-523-6574
Mailing address:
  • Phone: 770-740-1267
  • Fax: 404-523-6574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR093576
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: