1689027492 NPI number — KELSA SHIRLEY FNP

Table of content: KELSA SHIRLEY FNP (NPI 1689027492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689027492 NPI number — KELSA SHIRLEY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIRLEY
Provider First Name:
KELSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TEMPLE
Provider Other First Name:
KELSA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689027492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 CIRCLE J DR STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAUREL
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39440-1981
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-425-0092
Provider Business Mailing Address Fax Number:
601-425-0473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 CIRCLE J DR STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAUREL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39440-1981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-425-0092
Provider Business Practice Location Address Fax Number:
601-425-0473
Provider Enumeration Date:
07/16/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  901625 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 901625 . This is a "MS LICENSE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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