Provider Demographics
NPI:1073794533
Name:THOMPSON, KELLY R (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:119 AMBULANCE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8824
Mailing Address - Fax:770-838-8922
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:770-836-9666
Practice Address - Fax:770-836-8922
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN134604363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health