Provider Demographics
NPI:1942609664
Name:DEBAR, KELLEY (RN)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:DEBAR
Suffix:
Gender:F
Credentials:RN
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 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-947-8181
Mailing Address - Fax:601-947-4411
Practice Address - Street 1:92 RATLIFF ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6537
Practice Address - Country:US
Practice Address - Phone:601-947-8181
Practice Address - Fax:601-947-4411
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR859003163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR859003OtherSTATE LICENSURE
MSR859003OtherSTATE LICENSURE