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General NPI Number Information
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NPI Number | 1376184101
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Entity Type | Individual
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Provider Name | KELLY HASKELL PECZKA
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Gender | Female
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Dates
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Enumeration Date | 10/02/2019
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Last Update Date | 10/02/2019
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Provider Practice Location Address
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Address Line | 500 LANIER AVE W STE 702
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-7643
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Country | US
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Telephone | 413-250-7848
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Fax |
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Provider Business Mailing Address
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Address Line | 376 DINGLER RD
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City | MORELAND
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State | GA
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Zip | 30259-2229
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Country | US
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Telephone | 413-250-7848
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 009203
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License Number State | GA
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