Provider Demographics
NPI:1992836423
Name:MASK, KELLY SUSANNE (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUSANNE
Last Name:MASK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:SUSANNE
Other - Last Name:STEVISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2113 GOVERNMENT ST
Mailing Address - Street 2:BUILDING I-4
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3954
Mailing Address - Country:US
Mailing Address - Phone:228-818-0025
Mailing Address - Fax:228-818-0027
Practice Address - Street 1:2798 PASS RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2626
Practice Address - Country:US
Practice Address - Phone:228-200-0340
Practice Address - Fax:228-200-0341
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860508363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily