Provider Demographics
NPI:1922608025
Name:NGUYEN, KELLY TRANG
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:TRANG
Last Name:NGUYEN
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 1:392 ANNABEE CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-1515
Mailing Address - Country:US
Mailing Address - Phone:404-513-8741
Mailing Address - Fax:
Practice Address - Street 1:440 ATLANTA HWY NW
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-7826
Practice Address - Country:US
Practice Address - Phone:770-307-1272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH028602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist