Provider Demographics
NPI:1710096656
Name:ENGELMANN, KELLY BROOKE (CFNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:BROOKE
Last Name:ENGELMANN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 HONEYBEE CV
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7703
Mailing Address - Country:US
Mailing Address - Phone:601-862-1404
Mailing Address - Fax:
Practice Address - Street 1:1855 LAKELAND DR
Practice Address - Street 2:STE. M20
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4913
Practice Address - Country:US
Practice Address - Phone:601-364-1132
Practice Address - Fax:601-364-1134
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR805546363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSME1122744OtherDEA
MSME1122744OtherDEA