Provider Demographics
NPI:1023622081
Name:BALLARD, MARTY KYLE SR (FNP)
Entity type:Individual
Prefix:
First Name:MARTY
Middle Name:KYLE
Last Name:BALLARD
Suffix:SR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:698 LOWER BROOKHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-9627
Mailing Address - Country:US
Mailing Address - Phone:160-145-5760
Mailing Address - Fax:
Practice Address - Street 1:327 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3041
Practice Address - Country:US
Practice Address - Phone:601-833-3800
Practice Address - Fax:601-833-3847
Is Sole Proprietor?:No
Enumeration Date:2020-09-06
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily