Provider Demographics
NPI:1578031175
Name:CASTLEBERRY, KELLY (FCP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CASTLEBERRY
Suffix:
Gender:F
Credentials:FCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5067 WINDING BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-3901
Mailing Address - Country:US
Mailing Address - Phone:678-438-5431
Mailing Address - Fax:
Practice Address - Street 1:5067 WINDING BRANCH DR
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-3901
Practice Address - Country:US
Practice Address - Phone:678-438-5431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator