Healthcare Provider Details

I. General information

NPI: 1336754134
Provider Name (Legal Business Name): KELLIE ELIZABETH YEATES PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3675 J DEWEY GRAY CIR STE 300
AUGUSTA GA
30909-1868
US

IV. Provider business mailing address

PO BOX 3726
AUGUSTA GA
30914-3726
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-9595
  • Fax:
Mailing address:
  • Phone: 706-863-9595
  • Fax: 706-868-8375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10057
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: