Provider Demographics
NPI:1043349061
Name:KELSON, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:KELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MATANG
Other - Middle Name:MICHELL
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2575 RECREATION RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-5028
Mailing Address - Country:US
Mailing Address - Phone:478-743-5688
Mailing Address - Fax:
Practice Address - Street 1:2575 RECREATION RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-5028
Practice Address - Country:US
Practice Address - Phone:478-743-5688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver