Healthcare Provider Details

I. General information

NPI: 1417379538
Provider Name (Legal Business Name): KELLY TICKLE PCNS-BC, PPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2014
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5455 MERIDIAN MARKS RD STE 400
ATLANTA GA
30342-4723
US

IV. Provider business mailing address

5455 MERIDIAN MARKS RD STE 400
ATLANTA GA
30342-4723
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-3240
  • Fax: 404-785-3600
Mailing address:
  • Phone: 404-785-3240
  • Fax: 404-785-3600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN-NP228738
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN228738
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License NumberAPRN-CNS228738
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: