Provider Demographics
NPI:1649753773
Name:MCCARLEY, KELLY DIANE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:MCCARLEY
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 1:1908 TARVER DR
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-1540
Mailing Address - Country:US
Mailing Address - Phone:229-308-0460
Mailing Address - Fax:
Practice Address - Street 1:1908 TARVER DR
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-1540
Practice Address - Country:US
Practice Address - Phone:229-308-0460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN219753363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology