Provider Demographics
NPI:1093368631
Name:BAGI, KELLIE CLAYTON (CRNP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:CLAYTON
Last Name:BAGI
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BROWN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7005
Mailing Address - Country:US
Mailing Address - Phone:334-747-4159
Mailing Address - Fax:
Practice Address - Street 1:2065 E SOUTH BLVD STE 201
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2460
Practice Address - Country:US
Practice Address - Phone:334-747-7250
Practice Address - Fax:334-747-7270
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-148539363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner