MEDICARE: KEANNA NELSON CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SLP006202	GA

General Provider Information

NPI Number	:	1386635191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEANNA NELSON CCC-SLP

Provider Business Mailing Address
First Line	:	621 PAR THREE LN
Second Line	:
City	:	HAMPTON
State	:	GA
Zip	:	30228-6053
Country	:	US
Telephone Number	:	678-485-1470
Fax Number	:	678-826-4033

Provider Business Practice Location Address
First Line	:	1835 SAVOY DR
Second Line	:	SUITE 100
City	:	ATLANTA
State	:	GA
Zip	:	30341-1072
Country	:	US
Telephone Number	:	678-298-9484
Fax Number	:	678-826-4033

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2005
Last Update Date	:	01/30/2012

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Directions to “ KEANNA NELSON CCC-SLP” Practice Location

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