Provider Demographics
NPI:1699731679
Name:KELLEY, SANDRA K (CRNP)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:K
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CRNP
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 1038
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-1038
Mailing Address - Country:US
Mailing Address - Phone:706-653-8556
Mailing Address - Fax:706-653-9778
Practice Address - Street 1:1900 10TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3600
Practice Address - Country:US
Practice Address - Phone:706-653-8556
Practice Address - Fax:706-653-9778
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-081115363L00000X
GARN067940363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-30502OtherBLUE CROSS OF AL PROV #
AL891010421Medicaid
AL891010421Medicaid
AL051530502KELMedicare ID - Type UnspecifiedPROVIDER #