Basic Information
| Provider Information | |||||||||
| NPI: | 1184955635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TURNER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., LIC-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THISDALE | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A.,LIC-A | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5673 PEACHTREE DUNWOODY RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042971780 | ||||||||
| FaxNumber: | 4042527255 | ||||||||
| Practice Location | |||||||||
| Address1: | 5673 PEACHTREE DUNWOODY RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042971780 | ||||||||
| FaxNumber: | 4042527255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2010 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AUD003420 | GA | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 003101317H | 05 | GA | MEDICAID | 003101317I | 05 | GA | MEDICAID | 003101317F | 05 | GA | MEDICAID |