Basic Information
| Provider Information | |||||||||
| NPI: | 1225463060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | ANP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1199 PRINCE AVE | ||||||||
| Address2: | #7 | ||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306062797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064751700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1199 PRINCE AVE | ||||||||
| Address2: | #7 | ||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306062797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064751700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2013 | ||||||||
| LastUpdateDate: | 09/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN198482 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.