Provider Demographics
NPI:1376850719
Name:KELLY, CASSANDRA TERRESA (LPN)
Entity Type:Individual
Prefix:MS
First Name:CASSANDRA
Middle Name:TERRESA
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:CASSANDRA
Other - Middle Name:TERRESA
Other - Last Name:BEACH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:139 HENRY PKWY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6636
Mailing Address - Country:US
Mailing Address - Phone:770-898-7400
Mailing Address - Fax:770-898-7412
Practice Address - Street 1:139 HENRY PKWY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6636
Practice Address - Country:US
Practice Address - Phone:770-898-7400
Practice Address - Fax:770-898-7412
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN081087164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse