Provider Demographics
NPI:1275803108
Name:KELLY, SEAN PATRICK (ACNPC)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:PATRICK
Last Name:KELLY
Suffix:
Gender:M
Credentials:ACNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:2000 10TH AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3700
Practice Address - Country:US
Practice Address - Phone:706-571-1011
Practice Address - Fax:706-992-6595
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALCRNP 1-114327363L00000X
GARN228991363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner