Basic Information
| Provider Information | |||||||||
| NPI: | 1528431145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRANFORD | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | CONWILL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONWILL | ||||||||
| OtherFirstName: | KELLI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 315 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 BAPTIST DR STE 401 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391102012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019731517 | ||||||||
| FaxNumber: | 6019731623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2015 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 901375 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 09627870 | 05 | MS | MEDICAID |