Individual
KELLY COSTELLO BLACKMON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APRN
Contact information
Practice address
1706 ALICE ST, WAYCROSS, GA 31501-5216
(912) 285-1140
(912) 285-1125
Mailing address
PO BOX 749495, ATLANTA, GA 30374-9495
(855) 963-2100
(239) 236-2775
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
APRN-NP124057
GA
363LA2100X
Acute Care Nurse Practitioner
APRN-NP124057
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003154267A
—
GA
Enumeration date
06/22/2014
Last updated
10/15/2025
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