Provider Demographics
NPI:1023635166
Name:KELLEY, ALISA BRITNEY (FNP-C)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:BRITNEY
Last Name:KELLEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:MS
Mailing Address - Zip Code:39652-2834
Mailing Address - Country:US
Mailing Address - Phone:601-869-7330
Mailing Address - Fax:601-783-5812
Practice Address - Street 1:120 E MYRTLE ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:MS
Practice Address - Zip Code:39652-2834
Practice Address - Country:US
Practice Address - Phone:601-869-7330
Practice Address - Fax:601-783-5812
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-04
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903974363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily