Provider Demographics
NPI:1285068270
Name:KING, KELLI DEANNE (ACNP-BC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:DEANNE
Last Name:KING
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD
Mailing Address - Street 2:SUITE #103
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:901-227-4068
Mailing Address - Fax:
Practice Address - Street 1:255 BAPTIST BLVD
Practice Address - Street 2:STE 401
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2011
Practice Address - Country:US
Practice Address - Phone:662-244-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR876221363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care