Healthcare Provider Details

I. General information

NPI: 1649529108
Provider Name (Legal Business Name): JOAN IRENE KELLEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR.
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

3483 PRESERVE RUN TRAIL
LOGANVILLE GA
30052
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-2395
  • Fax: 678-990-3997
Mailing address:
  • Phone: 614-806-1355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN104467
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: