Provider Demographics
NPI:1982593935
Name:KELLY HEALTH & WELLNESS CLINIC LLC
Entity type:Organization
Organization Name:KELLY HEALTH & WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOBY
Authorized Official - Middle Name:G
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-219-3513
Mailing Address - Street 1:102 E CLAIBORNE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-3518
Mailing Address - Country:US
Mailing Address - Phone:662-219-3513
Mailing Address - Fax:662-219-3514
Practice Address - Street 1:102 E CLAIBORNE AVE STE D
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-3518
Practice Address - Country:US
Practice Address - Phone:662-219-3513
Practice Address - Fax:662-219-3514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-02
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty