Provider Demographics
NPI:1235885666
Name:PARRISH, KILEY JORDAN
Entity Type:Individual
Prefix:MS
First Name:KILEY
Middle Name:JORDAN
Last Name:PARRISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 GREENWOOD AVE NE APT 6
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3841
Mailing Address - Country:US
Mailing Address - Phone:631-965-0061
Mailing Address - Fax:
Practice Address - Street 1:201 MICHAEL ETCHISON RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-5996
Practice Address - Country:US
Practice Address - Phone:770-476-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA11043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program