Provider Demographics
NPI:1730478629
Name:NEELY, NICLAIRE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:NICLAIRE
Middle Name:LYNN
Last Name:NEELY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3225 SHALLOWFORD RD STE 500
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-7024
Mailing Address - Country:US
Mailing Address - Phone:678-757-4576
Mailing Address - Fax:605-309-8118
Practice Address - Street 1:3225 SHALLOWFORD RD STE 500
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7024
Practice Address - Country:US
Practice Address - Phone:678-757-4576
Practice Address - Fax:605-309-8118
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN11016023A2084P0800X
GA742022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry