Healthcare Provider Details

I. General information

NPI: 1255462230
Provider Name (Legal Business Name): GRACE PATRICIA KELLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5003 POPLAR SPRINGS DR
MERIDIAN MS
39305-1625
US

IV. Provider business mailing address

PO BOX 520
MARION MS
39342-0520
US

V. Phone/Fax

Practice location:
  • Phone: 601-453-5376
  • Fax: 888-735-7202
Mailing address:
  • Phone: 601-453-5393
  • Fax: 601-581-9936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMS11556
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: