Provider Demographics
NPI:1942287867
Name:CHUNN, KELLI R (ACNP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:R
Last Name:CHUNN
Suffix:
Gender:F
Credentials:ACNP
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 470
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-0470
Mailing Address - Country:US
Mailing Address - Phone:662-773-6211
Mailing Address - Fax:662-446-1039
Practice Address - Street 1:106 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2620
Practice Address - Country:US
Practice Address - Phone:662-773-5704
Practice Address - Fax:662-773-9463
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR762267363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124186Medicaid
P00191926OtherRAILROAD MEDICARE
MS00124186Medicaid
P00191926OtherRAILROAD MEDICARE