MEDICARE: MS. SANDRA K KELLEY CRNP

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	363L00000X	Nurse Practitioner	1-081115	AL
2	363LF0000X	Family Nurse Practitioner	RN067940	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	515-30502	OTHER	AL	BLUE CROSS OF AL PROV #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699731679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA K KELLEY CRNP

Provider Business Mailing Address
First Line	:	PO BOX 1038
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31902-1038
Country	:	US
Telephone Number	:	706-653-8556
Fax Number	:	706-653-9778

Provider Business Practice Location Address
First Line	:	1900 10TH AVE
Second Line	:	SUITE 200
City	:	COLUMBUS
State	:	GA
Zip	:	31901-3600
Country	:	US
Telephone Number	:	706-653-8556
Fax Number	:	706-653-9778

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

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	12/13/2013

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