Provider Demographics
NPI:1144742735
Name:KELLEY, WESLEY KYLE (NP)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:KYLE
Last Name:KELLEY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E SHOTWELL
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4256
Mailing Address - Country:US
Mailing Address - Phone:229-246-3500
Mailing Address - Fax:
Practice Address - Street 1:505 AMELIA AVE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4355
Practice Address - Country:US
Practice Address - Phone:229-243-6900
Practice Address - Fax:229-243-6919
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN230209363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003193034AMedicaid
GARN230209OtherMEDICAL LICENSE