Healthcare Provider Details

I. General information

NPI: 1164828372
Provider Name (Legal Business Name): KELLY COWAN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY RICHARD

II. Dates (important events)

Enumeration Date: 11/15/2014
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2781 C.T. SWITZER DRIVE SUITE 402
BILOXI MS
39531-4535
US

IV. Provider business mailing address

3704 SPRINGWOOD LN
OCEAN SPRINGS MS
39564-5051
US

V. Phone/Fax

Practice location:
  • Phone: 228-388-0949
  • Fax:
Mailing address:
  • Phone: 850-232-4361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR893568
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: