Provider Demographics
NPI:1720856552
Name:DEMENT, KELSEY MELANE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:MELANE
Last Name:DEMENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50228 GREENWOOD SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38848-8747
Mailing Address - Country:US
Mailing Address - Phone:662-436-3039
Mailing Address - Fax:
Practice Address - Street 1:50228 GREENWOOD SPRINGS RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38848-8747
Practice Address - Country:US
Practice Address - Phone:662-436-3039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS912758163W00000X
MS906449363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse