Provider Demographics
NPI:1841384443
Name:MARTIN, KELLEY N (CRNP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:N
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CRNP
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 530
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-0530
Mailing Address - Country:US
Mailing Address - Phone:601-845-6602
Mailing Address - Fax:601-845-6164
Practice Address - Street 1:218 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073
Practice Address - Country:US
Practice Address - Phone:601-845-6602
Practice Address - Fax:601-845-6164
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR814098363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122896Medicaid
MS00122896Medicaid