Provider Demographics
NPI:1558552257
Name:BLOGG, KELLIE MICHELLE (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:MICHELLE
Last Name:BLOGG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73709
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3709
Mailing Address - Country:US
Mailing Address - Phone:770-251-2060
Mailing Address - Fax:678-854-9235
Practice Address - Street 1:80 NEWNAN STATION DR STE A
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-3194
Practice Address - Country:US
Practice Address - Phone:770-251-2060
Practice Address - Fax:678-854-9235
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC215756367500000X
GARN118405367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA43ZCBFB181Medicare PIN