Provider Demographics
NPI:1598390296
Name:GATEWOOD, KAELIN JENYSE (NP)
Entity Type:Individual
Prefix:
First Name:KAELIN
Middle Name:JENYSE
Last Name:GATEWOOD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 HERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-8577
Mailing Address - Country:US
Mailing Address - Phone:770-527-5487
Mailing Address - Fax:
Practice Address - Street 1:3001 S COBB DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-7874
Practice Address - Country:US
Practice Address - Phone:404-296-7133
Practice Address - Fax:770-432-9139
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN233748363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty