Provider Demographics
NPI:1649939547
Name:PETTIS, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PETTIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 ARTILLERY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31903-4123
Mailing Address - Country:US
Mailing Address - Phone:706-840-9979
Mailing Address - Fax:
Practice Address - Street 1:22 ARTILLERY DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31903-4123
Practice Address - Country:US
Practice Address - Phone:706-840-9979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management