=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801540869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY CREEL FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2022
-----------------------------------------------------
Last Update Date | 02/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9481 CADE LN
-----------------------------------------------------
City | BAILEY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39320-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-616-9825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9481 CADE LN
-----------------------------------------------------
City | BAILEY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39320-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-616-9825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 905074
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------