Provider Demographics
NPI:1194815498
Name:PRATER WHITMORE, KELLY RAE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RAE
Last Name:PRATER WHITMORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 N POINT PKWY
Mailing Address - Street 2:STE 130
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5211
Mailing Address - Country:US
Mailing Address - Phone:770-740-1860
Mailing Address - Fax:678-347-2104
Practice Address - Street 1:394 S ALEXANDER CREEK RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-4132
Practice Address - Country:US
Practice Address - Phone:678-416-2472
Practice Address - Fax:678-423-5059
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3260225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3260OtherPT LICENSE NUMBER
GA323515OtherWELLCARE NUMBER
GA000837449BMedicaid