Provider Demographics
NPI:1063501344
Name:WHITTED, KELLI B (NP)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:B
Last Name:WHITTED
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2001 BROOKSTONE CENTRE PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904
Mailing Address - Country:US
Mailing Address - Phone:706-571-9699
Mailing Address - Fax:706-571-9565
Practice Address - Street 1:2001 BROOKSTONE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:706-571-9699
Practice Address - Fax:706-571-9565
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN117775208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN117775OtherLICENSE
GA739571899BMedicaid