Provider Demographics
NPI:1508125576
Name:TULLOS, KELLY NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:TULLOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:SHOEMAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-477-8553
Mailing Address - Fax:601-477-9158
Practice Address - Street 1:1440 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4243
Practice Address - Country:US
Practice Address - Phone:601-428-0577
Practice Address - Fax:601-426-9854
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS238412083B0002X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program