Provider Demographics
NPI:1487601050
Name:NATIONS, KELLY MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:NATIONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 THORNTON AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2157
Mailing Address - Country:US
Mailing Address - Phone:622-886-5356
Mailing Address - Fax:
Practice Address - Street 1:1510 THORNTON AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2157
Practice Address - Country:US
Practice Address - Phone:622-886-5356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17136207P00000X
LA024354207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1570427Medicaid
LA1570427Medicaid
MSH05247Medicare UPIN
LA4K447CQ60Medicare PIN