Healthcare Provider Details

I. General information

NPI: 1023319936
Provider Name (Legal Business Name): KISHA L KNIGHT FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KISHA L WALLER

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 LILLIE BURNEY ST
HATTIESBURG MS
39401-5505
US

IV. Provider business mailing address

PO BOX 1729
HATTIESBURG MS
39403-1729
US

V. Phone/Fax

Practice location:
  • Phone: 601-450-6500
  • Fax: 601-450-6503
Mailing address:
  • Phone: 601-545-3700
  • Fax: 601-450-2493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR863895
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: