Provider Demographics
NPI:1861784555
Name:KELLEHER, SONJA B (MD)
Entity type:Individual
Prefix:DR
First Name:SONJA
Middle Name:B
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SONJA
Other - Middle Name:GRACE LOUISE
Other - Last Name:BOULWARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:605 CLASSIC TRL
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-6010
Mailing Address - Country:US
Mailing Address - Phone:352-359-6129
Mailing Address - Fax:
Practice Address - Street 1:6401 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-5406
Practice Address - Country:US
Practice Address - Phone:352-359-6129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA072047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16874OtherTRAINING LICENSE