Blackmon, Kelly Costello

Blackmon, Kelly Costello is an individual health care provider with primary practice located at 1706 Alice St , Waycross GA 31501-5216. She recently has 2 registered licenses in different health care specialties including Physician Assistants & Advanced Practice Nursing Providers / Acute Care, Physician Assistants & Advanced Practice Nursing Providers / Nurse Practitioner. Physician Assistants & Advanced Practice Nursing Providers / Nurse Practitioner is her primary health care specialty. Blackmon, Kelly Costello can be contacted via phone (912) 285-1140.

Contact Information

Primary practice address
1706 Alice St Waycross GA 31501-5216
Phone: (912) 285-1140
Fax: (912) 285-1125
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Physician Assistants & Advanced Practice Nursing Providers / Acute Care 363LA2100X APRN-NP124057 Georgia
Physician Assistants & Advanced Practice Nursing Providers / Nurse Practitioner 363L00000X APRN-NP124057 Georgia

Profile Details

NPI number 1992110688
LBN Legal business name Blackmon, Kelly Costello
Credentials Advanced Practice Registered Nurse (APRN)
Entity Individual
Sole proprietor 1 No
Enumeration date Jun 22nd, 2014
Last updated Oct 15th, 2025 - about last year

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1992110688 NPPES
Georgia MEDICAID 003154267A

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