Healthcare Provider Details

I. General information

NPI: 1962804054
Provider Name (Legal Business Name): CHRISTAL KELLY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 SR-74 N STE 210
PEACHTREE CITY GA
30269
US

IV. Provider business mailing address

277 SR-74 N STE 210
PEACHTREE CITY GA
30269
US

V. Phone/Fax

Practice location:
  • Phone: 770-628-1097
  • Fax:
Mailing address:
  • Phone: 770-628-1097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP297065
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: