Provider Demographics
NPI:1427228816
Name:MUNDY, KELLY A (FNP, RNFA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:MUNDY
Suffix:
Gender:F
Credentials:FNP, RNFA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP, RNFA
Mailing Address - Street 1:6077 PRIMACY PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5742
Mailing Address - Country:US
Mailing Address - Phone:901-725-8347
Mailing Address - Fax:901-259-7637
Practice Address - Street 1:6286 BRIARCREST AVE STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-4023
Practice Address - Country:US
Practice Address - Phone:901-641-3000
Practice Address - Fax:901-259-1698
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN192906163W00000X, 163WR0006X
ARAOO5005363L00000X
MS901950363L00000X
TN17474363L00000X
TXAP128593363L00000X
TX890387363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS901950OtherMS LICENSE
TN17474OtherTN LICENSE
WV3810012886Medicaid
WV1073920OtherBWC
WVP00749322OtherRAILROAD MEDICARE
OH2852999Medicaid
NP27221Medicare PIN