Provider Demographics
NPI:1851757413
Name:THORNTON, KELLIE (NP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:830 S GLOSTER ST
Mailing Address - Street 2:1ST FLOOR EAST TOWER
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4934
Mailing Address - Country:US
Mailing Address - Phone:662-377-2395
Mailing Address - Fax:662-377-2397
Practice Address - Street 1:450 E PRESIDENT AVE
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5599
Practice Address - Country:US
Practice Address - Phone:662-377-4685
Practice Address - Fax:662-377-2755
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS901391363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology