Healthcare Provider Details

I. General information

NPI: 1851213839
Provider Name (Legal Business Name): DUSTIN KELLY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 09/27/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 LINDSAY RD
LENA MS
39094-9296
US

IV. Provider business mailing address

1915 LINDSAY RD
LENA MS
39094-9296
US

V. Phone/Fax

Practice location:
  • Phone: 601-572-9320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
License NumberNA
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number930879
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: