Healthcare Provider Details

I. General information

NPI: 1972237022
Provider Name (Legal Business Name): SHELDON REID KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 05/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HWY 30 W
NEW ALBANY MS
38652-3112
US

IV. Provider business mailing address

69 OAKLEY RD
THAXTON MS
38871-9703
US

V. Phone/Fax

Practice location:
  • Phone: 662-538-7631
  • Fax:
Mailing address:
  • Phone: 901-522-6745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number905406
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: