Provider Demographics
NPI:1407435068
Name:CLEGG, KELSEY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANN
Last Name:CLEGG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:ANN
Other - Last Name:NEWPORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1141 ELIAS STA
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-4172
Mailing Address - Country:US
Mailing Address - Phone:678-577-9920
Mailing Address - Fax:
Practice Address - Street 1:4244 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3087
Practice Address - Country:US
Practice Address - Phone:706-760-7607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant