Provider Demographics
NPI:1194290338
Name:WALL, KELLY WHITE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:WHITE
Last Name:WALL
Suffix:
Gender:F
Credentials:FNP-C
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 1416
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-1416
Mailing Address - Country:US
Mailing Address - Phone:706-833-6848
Mailing Address - Fax:
Practice Address - Street 1:414 LUGENIA DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-7210
Practice Address - Country:US
Practice Address - Phone:912-537-9355
Practice Address - Fax:912-335-4804
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN170495363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily