Provider Demographics
NPI:1932673902
Name:TALLY, KELLY (DPM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TALLY
Suffix:
Gender:F
Credentials:DPM
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Mailing Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 4105
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4541
Mailing Address - Country:US
Mailing Address - Phone:470-589-1204
Mailing Address - Fax:470-589-1465
Practice Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 4105
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4541
Practice Address - Country:US
Practice Address - Phone:470-589-1204
Practice Address - Fax:470-589-1465
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2023-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAPOD001396213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery