Provider Demographics
NPI:1619181997
Name:WINTER, KELLY DEAN (CP, LP)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:DEAN
Last Name:WINTER
Suffix:
Gender:M
Credentials:CP, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7675 LANIER VIEW RDG
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-2162
Mailing Address - Country:US
Mailing Address - Phone:770-844-1909
Mailing Address - Fax:
Practice Address - Street 1:7675 LANIER VIEW RDG
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-2162
Practice Address - Country:US
Practice Address - Phone:770-844-1909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
GA000034174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No174400000XOther Service ProvidersSpecialist