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General NPI Number Information
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NPI Number | 1093190514
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Entity Type | Individual
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Provider Name | KELLY MARIE PORCHE PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/27/2015
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Last Update Date | 03/21/2017
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Provider Practice Location Address
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Address Line | 2701 N DECATUR RD
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City | DECATUR
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State | GA
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Zip | 30033-5918
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Country | US
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Telephone | 678-230-4571
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Fax |
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Provider Business Mailing Address
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Address Line | 2795 ROXBURGH DR
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City | ROSWELL
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State | GA
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Zip | 30076-2450
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Country | US
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Telephone | 678-230-4571
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 8252
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License Number State | GA
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