Provider Demographics
NPI:1477345023
Name:PHILLIPS, KELLY (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:VAUGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 PENDLETON PL
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2632
Mailing Address - Country:US
Mailing Address - Phone:229-242-6868
Mailing Address - Fax:
Practice Address - Street 1:415 PENDLETON PL
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2632
Practice Address - Country:US
Practice Address - Phone:229-242-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA236257163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology