Healthcare Provider Details

I. General information

NPI: 1992836423
Provider Name (Legal Business Name): KELLY SUSANNE MASK N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY SUSANNE STEVISON N.P.

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 DENNY AVE STE 230
PASCAGOULA MS
39581-5307
US

IV. Provider business mailing address

3101 DENNY AVE STE 230
PASCAGOULA MS
39581-5307
US

V. Phone/Fax

Practice location:
  • Phone: 228-460-4180
  • Fax: 228-400-1140
Mailing address:
  • Phone: 228-460-4180
  • Fax: 228-400-1140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR860508
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: