Healthcare Provider Details

I. General information

NPI: 1770644288
Provider Name (Legal Business Name): KELLI ANNE MANNING ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 ANSLEY DR
DAHLONEGA GA
30533-1613
US

IV. Provider business mailing address

210 CRABAPPLE RD
DAHLONEGA GA
30533-4501
US

V. Phone/Fax

Practice location:
  • Phone: 706-864-7904
  • Fax:
Mailing address:
  • Phone: 706-867-1673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000753
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: