Provider Demographics
NPI:1710780119
Name:KELLIEBREW, ANGELA YVONNE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:YVONNE
Last Name:KELLIEBREW
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:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-0429
Mailing Address - Country:US
Mailing Address - Phone:404-289-0313
Mailing Address - Fax:
Practice Address - Street 1:4229 SNAPFINGER WOODS DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-3440
Practice Address - Country:US
Practice Address - Phone:404-286-9252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174400000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No174400000XOther Service ProvidersSpecialist