Provider Demographics
NPI:1548426323
Name:WEST, KELLY WITHERS (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:WITHERS
Last Name:WEST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAKE HEARN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1524
Mailing Address - Country:US
Mailing Address - Phone:404-256-9809
Mailing Address - Fax:
Practice Address - Street 1:1100 LAKE HEARN DR STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1524
Practice Address - Country:US
Practice Address - Phone:404-256-9809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65515208000000X
IL125050671208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65515OtherGEORGIA