Provider Demographics
NPI:1104277136
Name:ALEXANDER, KELLY PRINE (AGACNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:PRINE
Last Name:ALEXANDER
Suffix:
Gender:F
Credentials:AGACNP-BC
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 23457
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3457
Mailing Address - Country:US
Mailing Address - Phone:601-200-4466
Mailing Address - Fax:601-200-3651
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:601-200-4466
Practice Address - Fax:601-200-3651
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901619363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01770661OtherRAILROAD MEDICARE
MS542520YKHVOtherMEDICARE
MS07356036Medicaid