Healthcare Provider Details

I. General information

NPI: 1548872468
Provider Name (Legal Business Name): PHYLLIS KELLY WOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S 8TH ST
GRIFFIN GA
30224-4213
US

IV. Provider business mailing address

601 S 8TH ST
GRIFFIN GA
30224-4213
US

V. Phone/Fax

Practice location:
  • Phone: 770-467-6314
  • Fax: 770-467-6324
Mailing address:
  • Phone: 770-467-6314
  • Fax: 770-467-6324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN216745
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN216745
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: