Provider Demographics
NPI:1164672689
Name:SMALL, KEELY DIANNE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KEELY
Middle Name:DIANNE
Last Name:SMALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:DIANNE
Other - Last Name:POORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:556 3RD ST
Mailing Address - Street 2:STE A
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7993
Mailing Address - Country:US
Mailing Address - Phone:478-743-2472
Mailing Address - Fax:478-743-1516
Practice Address - Street 1:1014 FORSYTH ST
Practice Address - Street 2:STE 300
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2025
Practice Address - Country:US
Practice Address - Phone:478-633-8700
Practice Address - Fax:478-633-8710
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant