Healthcare Provider Details

I. General information

NPI: 1841879103
Provider Name (Legal Business Name): CYNTHIA KELSO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 MORROW CREST DR
HERNANDO MS
38632-7299
US

IV. Provider business mailing address

1070 MORROW CREST DR
HERNANDO MS
38632-7299
US

V. Phone/Fax

Practice location:
  • Phone: 901-216-4374
  • Fax:
Mailing address:
  • Phone: 901-216-4374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28322
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: