Provider Demographics
NPI:1750723771
Name:NEELY, KIMBERLY DIANE (CSFA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:NEELY
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4115 HIGHWAY 16 E
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30277-2220
Mailing Address - Country:US
Mailing Address - Phone:770-985-4257
Mailing Address - Fax:770-985-4258
Practice Address - Street 1:4115 HIGHWAY 16 E
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:GA
Practice Address - Zip Code:30277-2220
Practice Address - Country:US
Practice Address - Phone:770-985-4257
Practice Address - Fax:770-985-4258
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA142815208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery