Provider Demographics
NPI:1902061864
Name:WHARTON, KELLEY SUE (NP)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:SUE
Last Name:WHARTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4120 FIVE FORKS TRICKUM RD SW
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3130
Mailing Address - Country:US
Mailing Address - Phone:770-921-6900
Mailing Address - Fax:770-921-6313
Practice Address - Street 1:4120 FIVE FORKS TRICKUM RD SW
Practice Address - Street 2:SUITE 105
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3130
Practice Address - Country:US
Practice Address - Phone:770-921-6900
Practice Address - Fax:770-921-6313
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily