Healthcare Provider Details

I. General information

NPI: 1639279425
Provider Name (Legal Business Name): KAWANNA CORRINE MALONE C.F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAWANNA CORRINE TAYLOR C.F.N.P

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1495 MAPLE RD
NETTLETON MS
38858-6026
US

IV. Provider business mailing address

361 CR 122
NETTLETON MS
38858-6026
US

V. Phone/Fax

Practice location:
  • Phone: 662-963-9146
  • Fax: 662-963-9186
Mailing address:
  • Phone: 662-825-1086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR682403
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: