Provider Demographics
NPI:1588039143
Name:MACPHAUL, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MACPHAUL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11459 JOHNS CREEK PKWY STE 250
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-3517
Mailing Address - Country:US
Mailing Address - Phone:770-497-1555
Mailing Address - Fax:770-497-9998
Practice Address - Street 1:11459 JOHNS CREEK PKWY STE 250
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-3517
Practice Address - Country:US
Practice Address - Phone:770-497-1555
Practice Address - Fax:770-497-9998
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7846363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant