Provider Demographics
NPI:1679354765
Name:FEALY, KEVIN PATRICK III
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:FEALY
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 COBBLESTONE TRL
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-1225
Mailing Address - Country:US
Mailing Address - Phone:786-521-2198
Mailing Address - Fax:
Practice Address - Street 1:705 JUNIPER ST NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1307
Practice Address - Country:US
Practice Address - Phone:786-521-2198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide