Provider Demographics
NPI:1811408214
Name:RICHARDSON, KELLY (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:FNP-C
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 415000 MSC 410502
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37241-0001
Mailing Address - Country:US
Mailing Address - Phone:662-244-1088
Mailing Address - Fax:662-244-2088
Practice Address - Street 1:2520 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2008
Practice Address - Country:US
Practice Address - Phone:662-244-1489
Practice Address - Fax:662-244-1016
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902283363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner