Provider Demographics
NPI:1104070457
Name:ADAMS, KELLI NICHOLE (ACNP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:NICHOLE
Last Name:ADAMS
Suffix:
Gender:
Credentials:ACNP
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:NICHOLE
Other - Last Name:PASTRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:2578 HELEN HWY
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-2848
Practice Address - Country:US
Practice Address - Phone:770-219-9260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA164623363L00000X
GARN164623363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA957403077AEMedicaid
GA05953166OtherAMERIGROUP
GA957403077PMedicaid
GA957403077OMedicaid
GA957403077QMedicaid
GA957403077RMedicaid