Provider Demographics
NPI:1023092533
Name:KELLY, MARILYN RHOADS (NP)
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:RHOADS
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:202 N 1ST ST
Mailing Address - Street 2:STE A
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-2718
Mailing Address - Country:US
Mailing Address - Phone:662-340-1138
Mailing Address - Fax:662-728-5185
Practice Address - Street 1:202 N 1ST ST
Practice Address - Street 2:STE A
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2718
Practice Address - Country:US
Practice Address - Phone:662-340-1138
Practice Address - Fax:662-728-5185
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSR574996363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08138363Medicaid
MS08138363Medicaid
S51657Medicare UPIN