Provider Demographics
NPI:1528890118
Name:KELLY, ELIZABETH C
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 W WYNNGATE DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2858
Mailing Address - Country:US
Mailing Address - Phone:706-631-7828
Mailing Address - Fax:
Practice Address - Street 1:266 W WYNNGATE DR
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-2858
Practice Address - Country:US
Practice Address - Phone:706-631-7828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care