Provider Demographics
NPI:1063145902
Name:MARTIN, KELYN
Entity type:Individual
Prefix:
First Name:KELYN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4594
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-4594
Mailing Address - Country:US
Mailing Address - Phone:228-273-4096
Mailing Address - Fax:877-796-0186
Practice Address - Street 1:180B DEBUYS RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4404
Practice Address - Country:US
Practice Address - Phone:228-273-4096
Practice Address - Fax:877-796-0186
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905175363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS200001245Medicaid