Provider Demographics
NPI:1831968437
Name:GREENE, KELLY A (FNP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:GREENE
Suffix:
Gender:F
Credentials:FNP
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 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:638 OLD HISTORIC US 441
Practice Address - Street 2:SUITE B
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535
Practice Address - Country:US
Practice Address - Phone:770-501-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-22
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP001940363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily