Healthcare Provider Details

I. General information

NPI: 1992042402
Provider Name (Legal Business Name): KELLY D CAULLEY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2013
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11459 JOHNS CREEK PKWY SUITE 250
JOHNS CREEK GA
30097-3515
US

IV. Provider business mailing address

11459 JOHNS CREEK PKWY SUITE 250
JOHNS CREEK GA
30097-3515
US

V. Phone/Fax

Practice location:
  • Phone: 770-497-1555
  • Fax: 678-473-9877
Mailing address:
  • Phone: 770-497-1555
  • Fax: 678-473-9877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN133307 NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: