Provider Demographics
NPI:1578596946
Name:HATCHER, KELLIE ANNE (LD)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANNE
Last Name:HATCHER
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:ANNE
Other - Last Name:HARDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LD
Mailing Address - Street 1:920 HIGHWAY 84 WEST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792
Mailing Address - Country:US
Mailing Address - Phone:229-228-8857
Mailing Address - Fax:229-228-8891
Practice Address - Street 1:915 GORDON AVENUE AT MIMOSA DRIVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792
Practice Address - Country:US
Practice Address - Phone:229-228-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002441133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBRJMedicare ID - Type Unspecified
GAQ48200Medicare UPIN