Provider Demographics
NPI:1992110688
Name:BLACKMON, KELLY COSTELLO (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:COSTELLO
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:855-963-2100
Mailing Address - Fax:239-236-2775
Practice Address - Street 1:1706 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5216
Practice Address - Country:US
Practice Address - Phone:912-285-1140
Practice Address - Fax:912-285-1125
Is Sole Proprietor?:No
Enumeration Date:2014-06-22
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN124057363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003154267AMedicaid