Provider Demographics
NPI:1669576252
Name:WOOD, KELLY MICHELLE (CNM)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:WOOD
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MICHELLE
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-297-2200
Practice Address - Fax:770-534-8139
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN144656367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA123300944BMedicaid
GA359603OtherWELLCARE
GA123300944AMedicaid
GA123300944CMedicaid
GA123300944DMedicaid
GA10063406OtherAMERIGROUP
GA10063406OtherCIGNA
GA123300944BMedicaid