Provider Demographics
NPI:1043988496
Name:KELLY, KRISTAN S (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTAN
Middle Name:S
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 SHIELDS RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-9140
Mailing Address - Country:US
Mailing Address - Phone:601-513-2430
Mailing Address - Fax:
Practice Address - Street 1:1455 N LAKELAND DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-9020
Practice Address - Country:US
Practice Address - Phone:601-581-8450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904831363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily