Provider Demographics
NPI:1780849109
Name:MCLENDON, KILEY SELMAN (FNP)
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:SELMAN
Last Name:MCLENDON
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:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0490
Mailing Address - Country:US
Mailing Address - Phone:601-587-1433
Mailing Address - Fax:601-587-1625
Practice Address - Street 1:1135 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-7682
Practice Address - Country:US
Practice Address - Phone:601-587-1433
Practice Address - Fax:601-587-1625
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01452240Medicaid
MS01452240Medicaid