Healthcare Provider Details

I. General information

NPI: 1871083386
Provider Name (Legal Business Name): KENNETH A KRZYZKOWSKI NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 SOUTHCREST CIR STE 101
SOUTHAVEN MS
38671-4737
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-0755
  • Fax: 662-349-0356
Mailing address:
  • Phone: 901-226-4003
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number42623
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902566
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: