Provider Demographics
NPI:1336534064
Name:COBB, KELSEY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:
Last Name:COBB
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1110 BROAD AVE
Mailing Address - Street 2:STE 500
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-8902
Mailing Address - Country:US
Mailing Address - Phone:228-575-2588
Mailing Address - Fax:228-864-4154
Practice Address - Street 1:501 DR MICHAEL DEBAKEY DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5724
Practice Address - Country:US
Practice Address - Phone:337-433-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS894538363L00000X
TXAP127701363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA635971YH5NMedicare PIN