Provider Demographics
NPI:1811435175
Name:WALDROP, KELLY L (NNP-BC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:WALDROP
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:WALDROP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NNP-BC
Mailing Address - Street 1:5 RIVER BEND PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7618
Mailing Address - Country:US
Mailing Address - Phone:601-957-7345
Mailing Address - Fax:769-251-5429
Practice Address - Street 1:5 RIVER BEND PL
Practice Address - Street 2:SUITE C
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7618
Practice Address - Country:US
Practice Address - Phone:601-957-7345
Practice Address - Fax:769-251-5429
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSWAL104405434363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01874879Medicaid