Basic Information
| Provider Information | |||||||||
| NPI: | 1295110310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYNCH | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | GROMMERSCH | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | NORTHSIDE HOSPITAL - MANAGED CARE DEPARTMENT | ||||||||
| Address2: | 1000 JOHNSON FERRY RD NE ATLANTA | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303423034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048518097 | ||||||||
| FaxNumber: | 4042508010 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400C OLD MILTON PKWY STE 290 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300054438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706674343 | ||||||||
| FaxNumber: | 7707720937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2015 | ||||||||
| LastUpdateDate: | 03/07/2018 | ||||||||
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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 | 19544 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 19544 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | RN208756 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP3344 | 05 | SC | MEDICAID |