Basic Information
| Provider Information | |||||||||
| NPI: | 1639128218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRENSHAW | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CPNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOLDICK | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CPNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5455 MERIDIAN MARKS RD NE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042552033 | ||||||||
| FaxNumber: | 4042521901 | ||||||||
| Practice Location | |||||||||
| Address1: | 5455 MERIDIAN MARKS RD NE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042552033 | ||||||||
| FaxNumber: | 4042521901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | RN159090 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.