Healthcare Provider Details

I. General information

NPI: 1821259870
Provider Name (Legal Business Name): KELLY GLAZE WILLIAMS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 CHURCH ST NE STE 400
MARIETTA GA
30060-8957
US

IV. Provider business mailing address

PO BOX 3157
INDIANAPOLIS IN
46206-3157
US

V. Phone/Fax

Practice location:
  • Phone: 770-405-2976
  • Fax:
Mailing address:
  • Phone: 770-405-2976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number005343
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: