Provider Demographics
NPI:1861729709
Name:KELLEY, NICHOLAS OWEN (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:OWEN
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 CENTURY BLVD NE STE 150
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3323
Mailing Address - Country:US
Mailing Address - Phone:404-633-4595
Mailing Address - Fax:
Practice Address - Street 1:125 CLAIREMONT AVE STE 190
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030
Practice Address - Country:US
Practice Address - Phone:404-748-9691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35675208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC356750Medicaid
SC356750Medicaid