Basic Information
Provider Information | |||||||||
NPI: | 1609049089 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEMPHILL | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | EVERETT | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | EVERETT | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: | LEIGH | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 658 | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 305030658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7707181122 | ||||||||
FaxNumber: | 7705357445 | ||||||||
Practice Location | |||||||||
Address1: | 655 JESSE JEWELL PKWY SE | ||||||||
Address2: | STE B | ||||||||
City: | GAINESVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 305013756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7705327092 | ||||||||
FaxNumber: | 7705360383 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2008 | ||||||||
LastUpdateDate: | 08/24/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 5293 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 01357356 | 01 | GA | AMERIGROUP | OTHER | 587186 | 01 | GA | WELLCARE | OTHER | 742533948B | 05 | GA |   | MEDICAID | 742533948A | 05 | GA |   | MEDICAID |