Provider Demographics
NPI:1528768686
Name:HARLESS, KELLY VIRGA (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:VIRGA
Last Name:HARLESS
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 1:256 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2337
Mailing Address - Country:US
Mailing Address - Phone:678-712-4184
Mailing Address - Fax:770-353-9819
Practice Address - Street 1:256 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-2337
Practice Address - Country:US
Practice Address - Phone:678-712-4184
Practice Address - Fax:770-353-9819
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN214516163W00000X, 363LF0000X
GAF10220788363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse