Provider Demographics
NPI:1417455742
Name:KELLY, ROBIN
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROBYN
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:428A LAKE JOY RD
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-2024
Mailing Address - Country:US
Mailing Address - Phone:478-476-0805
Mailing Address - Fax:
Practice Address - Street 1:428A LAKE JOY RD
Practice Address - Street 2:
Practice Address - City:KATHLEEN
Practice Address - State:GA
Practice Address - Zip Code:31047-2024
Practice Address - Country:US
Practice Address - Phone:478-338-4062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2478568163W00000X
CA95209676163WP0808X
GALPN076817164W00000X
GA285373163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse