Healthcare Provider Details

I. General information

NPI: 1972439578
Provider Name (Legal Business Name): SHIREISLA DENAE KELLY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CROSS PARK DR
PEARL MS
39208-9016
US

IV. Provider business mailing address

855 SPRINGFIELD CT
RIDGELAND MS
39157-1583
US

V. Phone/Fax

Practice location:
  • Phone: 601-397-6731
  • Fax:
Mailing address:
  • Phone: 601-278-4933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number908520
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: