Provider Demographics
NPI:1033819511
Name:KELLY VELASQUEZ PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER, LLC
Entity Type:Organization
Organization Name:KELLY VELASQUEZ PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:VELASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:901-568-8843
Mailing Address - Street 1:1651 WOOD LANE DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7355
Mailing Address - Country:US
Mailing Address - Phone:901-568-8843
Mailing Address - Fax:
Practice Address - Street 1:7185 SWINNEA RD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6003
Practice Address - Country:US
Practice Address - Phone:901-568-8843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty