Provider Demographics
NPI:1154369700
Name:LAND, KELLY K (CFNP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:K
Last Name:LAND
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DEPT OF MEDICINE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5660
Mailing Address - Fax:
Practice Address - Street 1:2500 NORTH STATE ST
Practice Address - Street 2:DEPARTMENT OF MEDICINE DIVISION OF GENERAL INTERNAL MED
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5660
Practice Address - Fax:601-984-6870
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR855212207R00000X, 363L00000X
MAR855212363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0124222Medicaid
MS302I507206Medicare PIN
P39796Medicare UPIN
MS0124222Medicaid
MSP00821835Medicare PIN
MS512I500056Medicare PIN
MS500000921Medicare PIN