MEDICARE: MS. KELLI P. MOONEY FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	884545	MS

General Provider Information

NPI Number	:	1205288495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLI P. MOONEY FNP

Provider Business Mailing Address
First Line	:	7100 U S HIGHWAY 98 STE 220
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-8557
Country	:	US
Telephone Number	:	601-582-7655
Fax Number	:	601-582-3220

Provider Business Practice Location Address
First Line	:	7100 U S HIGHWAY 98 STE 220
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-8557
Country	:	US
Telephone Number	:	601-582-7655
Fax Number	:	601-582-3220

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2016
Last Update Date	:	07/12/2016

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