Provider Demographics
NPI:1609913896
Name:SKLARE, KELLY MOYNES (CNM, NP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MOYNES
Last Name:SKLARE
Suffix:
Gender:F
Credentials:CNM, NP-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:MOYNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 116156
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6156
Mailing Address - Country:US
Mailing Address - Phone:678-312-5525
Mailing Address - Fax:770-339-2120
Practice Address - Street 1:1942 ATKINSON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5004
Practice Address - Country:US
Practice Address - Phone:678-775-0600
Practice Address - Fax:678-377-5284
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN169833363LF0000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I500330Medicare UPIN