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General NPI Number Information
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NPI Number | 1346076015
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Entity Type | Individual
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Provider Name | KELLY ANN KONICKI LMT, CLT
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Gender | Female
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Dates
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Enumeration Date | 09/10/2024
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Last Update Date | 04/22/2025
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Provider Practice Location Address
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Address Line | 11180 STATE BRIDGE ROAD SUITE 404
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City | JOHNS CREEK
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State | GA
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Zip | 30022-7482
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Country | US
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Telephone | 678-871-7940
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Fax |
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Provider Business Mailing Address
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Address Line | 1405 TREERIDGE PKWY
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City | ALPHARETTA
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State | GA
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Zip | 30022-2830
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Country | US
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Telephone | 917-304-2672
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT002856
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License Number State | GA
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