Provider Demographics
NPI:1053192757
Name:KELLY, SHANELL N/A
Entity type:Individual
Prefix:
First Name:SHANELL
Middle Name:N/A
Last Name:KELLY
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 1:521 MANER TER SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-1995
Mailing Address - Country:US
Mailing Address - Phone:770-374-2523
Mailing Address - Fax:
Practice Address - Street 1:521 MANER TER SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-1995
Practice Address - Country:US
Practice Address - Phone:770-374-2523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant