Provider Demographics
NPI:1255462230
Name:KELLY, GRACE PATRICIA (MD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:PATRICIA
Last Name:KELLY
Suffix:
Gender:
Credentials:MD
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 520
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MS
Mailing Address - Zip Code:39342-0520
Mailing Address - Country:US
Mailing Address - Phone:601-453-5393
Mailing Address - Fax:601-581-9936
Practice Address - Street 1:5003 POPLAR SPRINGS DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-1625
Practice Address - Country:US
Practice Address - Phone:601-453-5376
Practice Address - Fax:888-735-7202
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS115562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00011284Medicaid
MSE73107Medicare UPIN
MS00011284Medicaid