Provider Demographics
NPI:1972271765
Name:MACK, KELLIE (ATC)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:709 ALLEN DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-6348
Mailing Address - Country:US
Mailing Address - Phone:912-373-2568
Mailing Address - Fax:
Practice Address - Street 1:709 ALLEN DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-6348
Practice Address - Country:US
Practice Address - Phone:912-373-2568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer