Healthcare Provider Details

I. General information

NPI: 1174877195
Provider Name (Legal Business Name): MRS. KELLY MARIE MCDOWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 PERSIMMON WAY
MCDONOUGH GA
30252-8438
US

IV. Provider business mailing address

3390 PEACHTREE NERD 1500
ATLANTA GA
30326-2822
US

V. Phone/Fax

Practice location:
  • Phone: 678-315-5766
  • Fax:
Mailing address:
  • Phone: 404-403-8310
  • Fax: 404-920-4959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN154424
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: