Provider Demographics
NPI:1164066338
Name:KELLEMS, CARLIE E
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:E
Last Name:KELLEMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39406-0002
Mailing Address - Country:US
Mailing Address - Phone:601-266-1000
Mailing Address - Fax:
Practice Address - Street 1:118 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406-0002
Practice Address - Country:US
Practice Address - Phone:601-266-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program