Provider Demographics
NPI:1801116942
Name:STEGALL, KELLY C (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:STEGALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 WATERS AVE STE 452
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6235
Mailing Address - Country:US
Mailing Address - Phone:912-350-5909
Mailing Address - Fax:912-350-5914
Practice Address - Street 1:4750 WATERS AVE STE 452
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404
Practice Address - Country:US
Practice Address - Phone:912-350-5909
Practice Address - Fax:912-350-5914
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN181599363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA839184162BMedicaid
SCNP1638Medicaid
GA01368785OtherAMERIGROUP
GAP00869909OtherRR MEDICARE
GA839184162AMedicaid
GA01368785OtherAMERIGROUP