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General NPI Number Information
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NPI Number | 1710780119
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Entity Type | Individual
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Provider Name | ANGELA YVONNE KELLIEBREW
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Gender | Female
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Dates
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Enumeration Date | 03/31/2025
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Last Update Date | 03/31/2025
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Provider Practice Location Address
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Address Line | 4229 SNAPFINGER WOODS DR
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City | DECATUR
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State | GA
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Zip | 30035-3440
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Country | US
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Telephone | 404-286-9252
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 429
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City | AVONDALE ESTATES
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State | GA
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Zip | 30002-0429
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Country | US
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Telephone | 404-289-0313
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State | GA
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