Provider Demographics
NPI:1275178915
Name:MACDONALD, KELLY BROOKS (CPNP-AC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:BROOKS
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7570 EASTON VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-8976
Mailing Address - Country:US
Mailing Address - Phone:703-609-9148
Mailing Address - Fax:
Practice Address - Street 1:1405 CLIFTON RD NE FL 4
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4052
Practice Address - Country:US
Practice Address - Phone:703-609-9148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-15
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN285784163W00000X, 363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical CareGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse