Provider Demographics
NPI:1629471727
Name:KERIVAN, FELICITY MARUM (PA-C)
Entity Type:Individual
Prefix:
First Name:FELICITY
Middle Name:MARUM
Last Name:KERIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:FELICITY
Other - Middle Name:
Other - Last Name:MARUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:900 CIRCLE 75 PKWY SE STE 1700
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3087
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:
Practice Address - Street 1:1265 HIGHWAY 54 W STE 102
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-496-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-02
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0004753363A00000X
GA7367363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant