Provider Demographics
NPI:1942987664
Name:KELLY, DUSTIN (FNP-C)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:KELLY
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 1:2055 COUNTY ROAD 240
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-6995
Mailing Address - Country:US
Mailing Address - Phone:662-299-5796
Mailing Address - Fax:
Practice Address - Street 1:1117 SUNSET DR STE 101
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4080
Practice Address - Country:US
Practice Address - Phone:662-226-1168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS899168163W00000X
MS906082363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse