Healthcare Provider Details

I. General information

NPI: 1710517388
Provider Name (Legal Business Name): KELLY SKONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 04/09/2023
Certification Date: 04/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3872 HIGHWAY 5
DOUGLASVILLE GA
30135-3366
US

IV. Provider business mailing address

180 SADDLE HORSE LN
HIRAM GA
30141-2379
US

V. Phone/Fax

Practice location:
  • Phone: 770-949-5535
  • Fax:
Mailing address:
  • Phone: 714-745-4458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN267340
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: