Provider Demographics
NPI:1629528450
Name:WIEDOWER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WIEDOWER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 PRINCETON LN
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-5338
Mailing Address - Country:US
Mailing Address - Phone:706-254-3250
Mailing Address - Fax:
Practice Address - Street 1:1041 PARK DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-3465
Practice Address - Country:US
Practice Address - Phone:706-453-4945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA213342363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily