1922726512 NPI number — MRS. KELLY LYNN VELASQUEZ PMHNP

Table of content: MRS. KELLY LYNN VELASQUEZ PMHNP (NPI 1922726512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922726512 NPI number — MRS. KELLY LYNN VELASQUEZ PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VELASQUEZ
Provider First Name:
KELLY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1922726512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1651 WOOD LANE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLIVE BRANCH
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38654-7355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-568-8843
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6858 SWINNEA RD BLDG 3B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-9493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-420-2418
Provider Business Practice Location Address Fax Number:
855-529-1633
Provider Enumeration Date:
08/18/2022

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: 363LP0808X , with the licence number:  905496 , 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)





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