Provider Demographics
NPI:1457921249
Name:KELLY, KIANA LANIECE
Entity Type:Individual
Prefix:
First Name:KIANA
Middle Name:LANIECE
Last Name:KELLY
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 1:2058 GLENN FLS
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5498
Mailing Address - Country:US
Mailing Address - Phone:762-444-4674
Mailing Address - Fax:
Practice Address - Street 1:2058 GLENN FLS
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-5498
Practice Address - Country:US
Practice Address - Phone:762-444-4674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer