Provider Demographics
NPI:1093117368
Name:EARLS, KELLI C (PAAA)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:C
Last Name:EARLS
Suffix:
Gender:F
Credentials:PAAA
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:CORLESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3155 N POINT PKWY STE F100
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5495
Mailing Address - Country:US
Mailing Address - Phone:770-645-9181
Mailing Address - Fax:770-645-8455
Practice Address - Street 1:1000 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:770-645-9181
Practice Address - Fax:770-645-8455
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007317367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003151324AMedicaid
GA003151324AMedicaid