Provider Demographics
NPI:1386659928
Name:NIX, KELLY BRUMBELOW (FNP, BC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:BRUMBELOW
Last Name:NIX
Suffix:
Gender:F
Credentials:FNP, BC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:D
Other - Last Name:BRUMBELOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP, BC
Mailing Address - Street 1:145 N MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-7031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 N MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189
Practice Address - Country:US
Practice Address - Phone:770-592-3000
Practice Address - Fax:770-999-2650
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA112048363L00000X
GARN112048363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA316257111AMedicaid
GA50BBGRVMedicare ID - Type UnspecifiedMEDICARE
GA316257111AMedicaid