Healthcare Provider Details

I. General information

NPI: 1053339200
Provider Name (Legal Business Name): CARRIE KELLY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 01/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 JAMESTOWN BLVD BLDG 200
WATKINSVILLE GA
30677-4131
US

IV. Provider business mailing address

PO BOX 48089 STE. A
ATHENS GA
30604-8089
US

V. Phone/Fax

Practice location:
  • Phone: 706-769-0005
  • Fax:
Mailing address:
  • Phone: 706-769-0005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTL28040
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61103
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: