Healthcare Provider Details

I. General information

NPI: 1083107502
Provider Name (Legal Business Name): KELSEY MILLER DYES CPNP-AC/PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2018
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1062 FORSYTH ST STE 3A
MACON GA
31201-8640
US

IV. Provider business mailing address

2835 BRANDYWINE RD STE 400
ATLANTA GA
30341-5540
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-2593
  • Fax:
Mailing address:
  • Phone: 404-256-2593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN051783939
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberRN235412
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN235412
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: