Provider Demographics
NPI:1023566387
Name:ADDISON, KALLI PELAR COLEMAN (ATC/LAT, EMT-I)
Entity Type:Individual
Prefix:
First Name:KALLI
Middle Name:PELAR COLEMAN
Last Name:ADDISON
Suffix:
Gender:F
Credentials:ATC/LAT, EMT-I
Other - Prefix:
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Mailing Address - Street 1:123 CHANDLER DR
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-6139
Mailing Address - Country:US
Mailing Address - Phone:706-473-4497
Mailing Address - Fax:
Practice Address - Street 1:131 CYPRESS LN
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-7567
Practice Address - Country:US
Practice Address - Phone:706-473-4497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAI-40267146M00000X
GAAT0027312255A2300X
GARN297931363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer