Provider Demographics
NPI:1992566178
Name:COCKRELL, KELLI (MS, ATC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:COCKRELL
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 FAIRWAY PL
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3606
Mailing Address - Country:US
Mailing Address - Phone:601-606-3550
Mailing Address - Fax:
Practice Address - Street 1:86 FAIRWAY PL
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3606
Practice Address - Country:US
Practice Address - Phone:601-606-3550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS080802008207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine