Provider Demographics
NPI:1972237022
Name:KELLY, SHELDON REID
Entity Type:Individual
Prefix:
First Name:SHELDON
Middle Name:REID
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 OAKLEY RD
Mailing Address - Street 2:
Mailing Address - City:THAXTON
Mailing Address - State:MS
Mailing Address - Zip Code:38871-9703
Mailing Address - Country:US
Mailing Address - Phone:901-522-6745
Mailing Address - Fax:
Practice Address - Street 1:200 HWY 30 W
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3112
Practice Address - Country:US
Practice Address - Phone:662-538-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905406363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care