Provider Demographics
NPI:1366954240
Name:BRISTER, KELLI POTTER (NP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:POTTER
Last Name:BRISTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:NICOLE
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 22727
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2727
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-4644
Practice Address - Fax:601-200-4645
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902342363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily