Provider Demographics
NPI:1790234953
Name:STOTSKY, KELLIE JO
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:JO
Last Name:STOTSKY
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 1:303 MEDICAL DR
Mailing Address - Street 2:SUITE 405
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4169
Mailing Address - Country:US
Mailing Address - Phone:706-242-5099
Mailing Address - Fax:706-242-5231
Practice Address - Street 1:303 MEDICAL DR
Practice Address - Street 2:SUITE 405
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4169
Practice Address - Country:US
Practice Address - Phone:706-242-5099
Practice Address - Fax:706-242-5231
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FMRN262321367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife