Provider Demographics
NPI:1659741429
Name:STATHAM, KELLY COLEMAN (AGPCNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:COLEMAN
Last Name:STATHAM
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:MISS
Other - First Name:CATHERINE
Other - Middle Name:KELLY
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3980 COLONNADE PKWY
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2382
Mailing Address - Country:US
Mailing Address - Phone:205-599-3525
Mailing Address - Fax:
Practice Address - Street 1:3980 COLONNADE PKWY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-2382
Practice Address - Country:US
Practice Address - Phone:205-599-3525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-126752363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner