1811435175 NPI number — KELLY L WALDROP NNP-BC

Table of content: KELLY L WALDROP NNP-BC (NPI 1811435175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811435175 NPI number — KELLY L WALDROP NNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALDROP
Provider First Name:
KELLY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALDROP
Provider Other First Name:
KELLY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NNP-BC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1811435175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 RIVER BEND PL
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-7618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-957-7345
Provider Business Mailing Address Fax Number:
769-251-5429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 RIVER BEND PL
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-7618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-957-7345
Provider Business Practice Location Address Fax Number:
769-251-5429
Provider Enumeration Date:
02/07/2017

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: 363LN0000X , with the licence number:  WAL104405434 , 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: 01874879 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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