Provider Demographics
NPI:1336542943
Name:PACK, KELLIE (NP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:PACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 J L WHITE DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-4893
Mailing Address - Country:US
Mailing Address - Phone:706-692-3539
Mailing Address - Fax:
Practice Address - Street 1:220 J L WHITE DR
Practice Address - Street 2:SUITE 120
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-4893
Practice Address - Country:US
Practice Address - Phone:706-692-3539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-27
Last Update Date:2014-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN197369363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily