Healthcare Provider Details

I. General information

NPI: 1720856552
Provider Name (Legal Business Name): KELSEY MELANE DEMENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 07/25/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 SOUTH STREET
CALEDONIA MS
39740
US

IV. Provider business mailing address

50228 GREENWOOD SPRINGS RD
GREENWOOD SPRINGS MS
38848-8747
US

V. Phone/Fax

Practice location:
  • Phone: 662-356-1560
  • Fax: 662-356-1569
Mailing address:
  • Phone: 662-436-3039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906449
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number912758
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: