Healthcare Provider Details

I. General information

NPI: 1487639019
Provider Name (Legal Business Name): KRISTA K HODGE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTA K. WADE F.NP

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6941 HIGHWAY 11 STE A
CARRIERE MS
39426-7794
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-749-3714
  • Fax: 601-749-3776
Mailing address:
  • Phone: 601-749-3714
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number767181
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR767181
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: