Provider Demographics
NPI:1124687348
Name:KUSHINKA, KELLI MARIE (NP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:KUSHINKA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8818
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31095-8818
Mailing Address - Country:US
Mailing Address - Phone:478-923-0131
Mailing Address - Fax:478-922-6530
Practice Address - Street 1:116 S HOUSTON RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3904
Practice Address - Country:US
Practice Address - Phone:478-923-0131
Practice Address - Fax:478-922-6530
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN250344363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN250344OtherRN
GA201913531OtherNP CERTIFICATION