Provider Demographics
NPI:1063056760
Name:GLADDEN, KELLY W (RRT, RPSGT, CCSH RST)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:W
Last Name:GLADDEN
Suffix:
Gender:F
Credentials:RRT, RPSGT, CCSH RST
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:WALKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:575 CRICKLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-8544
Mailing Address - Country:US
Mailing Address - Phone:678-849-6943
Mailing Address - Fax:
Practice Address - Street 1:2540 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8605
Practice Address - Country:US
Practice Address - Phone:678-849-6943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
305246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other