Healthcare Provider Details

I. General information

NPI: 1871380600
Provider Name (Legal Business Name): MARY EDITH KELLOGG FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 14TH ST
MERIDIAN MS
39301-4040
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 601-553-6000
  • Fax:
Mailing address:
  • Phone: 901-226-4003
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906825
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: