Healthcare Provider Details

I. General information

NPI: 1942118229
Provider Name (Legal Business Name): KELLYE RICHARDSON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3090 E FAIRVIEW RD
MCDONOUGH GA
30252-8118
US

IV. Provider business mailing address

3090 E FAIRVIEW RD
MCDONOUGH GA
30252-8118
US

V. Phone/Fax

Practice location:
  • Phone: 678-758-2405
  • Fax:
Mailing address:
  • Phone: 678-758-2405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP244701
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: