Provider Demographics
NPI:1831639293
Name:ANDERSON, KELLY LYNN (ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 PLEASANT HILL RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1407
Mailing Address - Country:US
Mailing Address - Phone:678-312-7880
Mailing Address - Fax:678-312-7890
Practice Address - Street 1:3855 PLEASANT HILL RD
Practice Address - Street 2:SUITE 130
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1407
Practice Address - Country:US
Practice Address - Phone:678-312-7880
Practice Address - Fax:678-312-7890
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0608024162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer