Provider Demographics
NPI:1215937578
Name:SHELLEY, KATHRYN JOAN (PA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JOAN
Last Name:SHELLEY
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 INTERSTATE NORTH CIR SE STE 50
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2227
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:
Practice Address - Street 1:1240 EAGLES LANDING PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-506-4350
Practice Address - Fax:770-506-9860
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA154965700BMedicaid
GAN270018OtherWELLCARE MEDICAID
GAP00083326OtherRAILROAD MEDICARE
GA154965700AMedicaid
GA154965700AMedicaid
GAN270018OtherWELLCARE MEDICAID