Provider Demographics
NPI:1083874119
Name:HARBIN, MARY KELLY (NP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KELLY
Last Name:HARBIN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KELLY
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15 RIVERBEND DR SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6005
Mailing Address - Country:US
Mailing Address - Phone:706-295-5331
Mailing Address - Fax:
Practice Address - Street 1:1825 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1625
Practice Address - Country:US
Practice Address - Phone:706-238-8012
Practice Address - Fax:706-238-8013
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN155084363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003105007AMedicaid
GA202I505836Medicare PIN