Provider Demographics
NPI:1174835334
Name:O'KEEFE-WATSON, KELLY (PA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:O'KEEFE-WATSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:512 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4325
Practice Address - Country:US
Practice Address - Phone:912-369-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-05
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.712363A00000X
GA5849363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20297I6144OtherMEDICARE PTAN
GA003105013Medicaid
AL170095Medicaid