Provider Demographics
NPI:1154684363
Name:FEWELL, KELLI S (NNP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:S
Last Name:FEWELL
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-3994
Mailing Address - Country:US
Mailing Address - Phone:601-439-7221
Mailing Address - Fax:601-721-1773
Practice Address - Street 1:610 3RD ST SW
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3994
Practice Address - Country:US
Practice Address - Phone:601-439-7221
Practice Address - Fax:601-721-1773
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR879688363LN0000X, 363LN0005X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04038362Medicaid
MS004038362Medicaid