Provider Demographics
NPI:1063256022
Name:VERNOR, KELLIE MICHELLE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MICHELLE
Last Name:VERNOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1389 WEBER INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6468
Mailing Address - Country:US
Mailing Address - Phone:770-886-6204
Mailing Address - Fax:678-261-6421
Practice Address - Street 1:6002 HIGHWAY 53 E STE 110
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6227
Practice Address - Country:US
Practice Address - Phone:770-767-1971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP012014235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist