Provider Demographics
NPI:1346887353
Name:FOSTER, KELLI MARIE (APRN NP-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:FOSTER
Suffix:
Gender:F
Credentials:APRN NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 BELLE OAK PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-8111
Mailing Address - Country:US
Mailing Address - Phone:601-397-0947
Mailing Address - Fax:
Practice Address - Street 1:1055 HIGHWAY 49 S STE B
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-7517
Practice Address - Country:US
Practice Address - Phone:601-829-6151
Practice Address - Fax:769-241-0044
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09935368Medicaid