Healthcare Provider Details

I. General information

NPI: 1679019350
Provider Name (Legal Business Name): KRISTEN WALLACE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 FLOWOOD DR
FLOWOOD MS
39232-9019
US

IV. Provider business mailing address

2470 FLOWOOD DR
FLOWOOD MS
39232-9019
US

V. Phone/Fax

Practice location:
  • Phone: 601-664-1213
  • Fax: 601-932-8869
Mailing address:
  • Phone: 601-664-1213
  • Fax: 601-932-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901914
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: