Provider Demographics
NPI:1710535307
Name:ANDERSON, KELLY TAYLOR (CAA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:TAYLOR
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAA
Mailing Address - Street 1:1000 JOHNSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1606
Mailing Address - Country:US
Mailing Address - Phone:404-851-8917
Mailing Address - Fax:404-303-3636
Practice Address - Street 1:1000 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-8917
Practice Address - Fax:404-303-3636
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9526367H00000X
367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant