Provider Demographics
NPI:1386635191
Name:NELSON, KEANNA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KEANNA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 MCINTOSH PLACE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7384
Mailing Address - Country:US
Mailing Address - Phone:678-485-1470
Mailing Address - Fax:470-377-8097
Practice Address - Street 1:175 BRADFORD SQ STE A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215
Practice Address - Country:US
Practice Address - Phone:678-438-7168
Practice Address - Fax:470-377-8097
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-01
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006202235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist