Provider Demographics
NPI:1750492203
Name:THORNTON, KELLY S (FNP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:S
Last Name:THORNTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-7954
Mailing Address - Country:US
Mailing Address - Phone:662-286-0909
Mailing Address - Fax:662-286-0110
Practice Address - Street 1:2209 N 2ND ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-7734
Practice Address - Country:US
Practice Address - Phone:662-728-0162
Practice Address - Fax:662-728-0326
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00086795Medicaid
MS500002281Medicare PIN
MS00086795Medicaid