Healthcare Provider Details

I. General information

NPI: 1083336994
Provider Name (Legal Business Name): KELLY KOTOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TOWER RD NE
MARIETTA GA
30060-9411
US

IV. Provider business mailing address

677 CHURCH ST NE
MARIETTA GA
30060-1101
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-1372
  • Fax:
Mailing address:
  • Phone: 770-793-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN259635
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: