Provider Demographics
NPI:1700179900
Name:DOUB, KELLY M (NNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:M
Last Name:DOUB
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8147
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-8147
Mailing Address - Country:US
Mailing Address - Phone:706-320-2773
Mailing Address - Fax:706-596-4226
Practice Address - Street 1:2122 MANCHESTER EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:706-320-2773
Practice Address - Fax:706-596-4226
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169365363LN0000X
GARN226465363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL167215Medicaid
GA003129046EMedicaid