Healthcare Provider Details

I. General information

NPI: 1548838428
Provider Name (Legal Business Name): KELLY CARPENTER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 EISENHOWER DR
SAVANNAH GA
31406-5027
US

IV. Provider business mailing address

139 FAIRGREEN ST
SAVANNAH GA
31407-3909
US

V. Phone/Fax

Practice location:
  • Phone: 912-303-1601
  • Fax:
Mailing address:
  • Phone: 912-655-6402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number240992
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN240992
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: