Healthcare Provider Details

I. General information

NPI: 1508125576
Provider Name (Legal Business Name): KELLY NICOLE TULLOS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY NICOLE SHOEMAKE

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 JEFFERSON ST
LAUREL MS
39440-4243
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-428-0577
  • Fax: 601-426-9854
Mailing address:
  • Phone: 601-477-8553
  • Fax: 601-477-9158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number23841
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23841
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: