Provider Demographics
NPI:1083237689
Name:KELLY, CASSIE JO (FNP)
Entity Type:Individual
Prefix:MRS
First Name:CASSIE
Middle Name:JO
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CASSIE
Other - Middle Name:JO
Other - Last Name:SHARMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 PADDLE WHEEL DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-9122
Mailing Address - Country:US
Mailing Address - Phone:706-302-3833
Mailing Address - Fax:
Practice Address - Street 1:1075 LAFAYETTE PKWY
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-3504
Practice Address - Country:US
Practice Address - Phone:706-443-5273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN222812363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily