Provider Demographics
NPI:1457062713
Name:NANCE-JUDGE, KELSEY ANN (PTA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANN
Last Name:NANCE-JUDGE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 WINTON WAY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-3818
Mailing Address - Country:US
Mailing Address - Phone:678-773-4368
Mailing Address - Fax:
Practice Address - Street 1:875 FLAT SHOALS RD SE STE 150
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6640
Practice Address - Country:US
Practice Address - Phone:770-785-7669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004961225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant