Provider Demographics
NPI:1497798532
Name:ELLIOTT, KELLY RAY (FNP)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:RAY
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2976 HIGHWAY 76
Mailing Address - Street 2:STE B&C
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-6981
Mailing Address - Country:US
Mailing Address - Phone:706-517-0656
Mailing Address - Fax:706-517-0651
Practice Address - Street 1:2976 HIGHWAY 76
Practice Address - Street 2:STE B&C
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-6981
Practice Address - Country:US
Practice Address - Phone:706-517-0656
Practice Address - Fax:706-517-0651
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA977575363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA777482691Medicaid