Provider Demographics
NPI:1710522198
Name:KELLEWAY, LAURA NICOLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:NICOLE
Last Name:KELLEWAY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:NICOLE
Other - Last Name:HEABERLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23 COUNTY ROAD 205
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-9794
Mailing Address - Country:US
Mailing Address - Phone:901-268-9862
Mailing Address - Fax:
Practice Address - Street 1:23 COUNTY ROAD 205
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-9794
Practice Address - Country:US
Practice Address - Phone:901-268-9862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-09
Last Update Date:2019-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily