Basic Information
| Provider Information | |||||||||
| NPI: | 1285068270 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | DEANNE | ||||||||
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| Credential: | ACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD | ||||||||
| Address2: | SUITE #103 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012274068 | ||||||||
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| Practice Location | |||||||||
| Address1: | 255 BAPTIST BLVD | ||||||||
| Address2: | STE 401 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397052011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622442288 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2013 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | R876221 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.