Healthcare Provider Details

I. General information

NPI: 1992944870
Provider Name (Legal Business Name): KIMBERLY ANN KELLY L.P.C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 01/29/2025
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2164 SOUTHRIDGE DR
TUPELO MS
38801-6417
US

IV. Provider business mailing address

238 COUNTY ROAD 2446
GUNTOWN MS
38849-9106
US

V. Phone/Fax

Practice location:
  • Phone: 662-760-0115
  • Fax: 662-596-0428
Mailing address:
  • Phone: 662-760-0115
  • Fax: 662-596-0428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1923
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1923
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number1923
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: