Healthcare Provider Details

I. General information

NPI: 1942609664
Provider Name (Legal Business Name): KELLEY DEBAR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 RATLIFF ST
LUCEDALE MS
39452-6537
US

IV. Provider business mailing address

PO BOX 1007
LUCEDALE MS
39452-1007
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-8181
  • Fax: 601-947-4411
Mailing address:
  • Phone: 601-947-8181
  • Fax: 601-947-4411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR859003
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR859003
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: