Basic Information
| Provider Information | |||||||||
| NPI: | 1275289100 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLNER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | GLADNEY | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5304 BURDOCK CRK NW | ||||||||
| Address2: | |||||||||
| City: | ACWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301017873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049666950 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE STE 250 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704284475 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2022 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN240926 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.