Healthcare Provider Details

I. General information

NPI: 1164672689
Provider Name (Legal Business Name): KEELY DIANNE SMALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KEELY DIANNE POORE PA-C

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 FORSYTH ST STE 300
MACON GA
31201-2025
US

IV. Provider business mailing address

556 3RD ST STE A
MACON GA
31201-7993
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-8700
  • Fax: 478-633-8710
Mailing address:
  • Phone: 478-743-2472
  • Fax: 478-743-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: