Provider Demographics
NPI:1477061257
Name:THOMAS, KELLEY SHYNELLE
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:SHYNELLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 OLD HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-4356
Mailing Address - Country:US
Mailing Address - Phone:678-789-4261
Mailing Address - Fax:
Practice Address - Street 1:1730 OLD HICKORY ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-4356
Practice Address - Country:US
Practice Address - Phone:678-789-4261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide