Healthcare Provider Details

I. General information

NPI: 1487236295
Provider Name (Legal Business Name): KELLY DYESS JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN KELLY DYESS

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 13TH ST
GULFPORT MS
39501-2515
US

IV. Provider business mailing address

4500 13TH ST
GULFPORT MS
39501-2515
US

V. Phone/Fax

Practice location:
  • Phone: 228-867-4000
  • Fax:
Mailing address:
  • Phone: 228-867-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36112
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: