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General NPI Number Information
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NPI Number | 1730478629
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Entity Type | Individual
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Provider Name | NICLAIRE LYNN NEELY MD
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Gender | Female
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Dates
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Enumeration Date | 03/31/2011
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Last Update Date | 12/30/2021
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Provider Practice Location Address
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Address Line | 3225 SHALLOWFORD RD STE 500
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City | MARIETTA
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State | GA
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Zip | 30062-7024
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Country | US
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Telephone | 678-757-4576
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Fax | 605-309-8118
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Provider Business Mailing Address
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Address Line | 3225 SHALLOWFORD RD STE 500
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City | MARIETTA
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State | GA
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Zip | 30062-7024
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Country | US
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Telephone | 678-757-4576
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Fax | 605-309-8118
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 11016023A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 74202
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License Number State | GA
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