Provider Demographics
NPI:1922759489
Name:GARRETT, KELLIE BAKER
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:BAKER
Last Name:GARRETT
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 1:20 LINDBERG DR NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-5166
Mailing Address - Country:US
Mailing Address - Phone:706-331-4129
Mailing Address - Fax:
Practice Address - Street 1:710 N 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2704
Practice Address - Country:US
Practice Address - Phone:706-331-4129
Practice Address - Fax:706-291-2558
Is Sole Proprietor?:No
Enumeration Date:2022-01-15
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018228183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1104049Medicaid