Provider Demographics
NPI:1831161090
Name:KELLY, ELIZABETH ANN (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:55 RE JENNINGS AVE SE
Mailing Address - Street 2:P.O. DRAWER R
Mailing Address - City:ARLINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:39813-8722
Mailing Address - Country:US
Mailing Address - Phone:229-725-4272
Mailing Address - Fax:229-725-2199
Practice Address - Street 1:103 RE JENNINGS AVE SE
Practice Address - Street 2:P.O. DRAWER R
Practice Address - City:ARLINGTON
Practice Address - State:GA
Practice Address - Zip Code:39813-8725
Practice Address - Country:US
Practice Address - Phone:229-725-4251
Practice Address - Fax:229-725-2212
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN050989163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBHWRMedicare ID - Type Unspecified
GAQ27641Medicare UPIN
50BBLRBMedicare PIN