Healthcare Provider Details

I. General information

NPI: 1942150610
Provider Name (Legal Business Name): KRISTIN LODGE WALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W TRADE ST
DALLAS NC
28034-1543
US

IV. Provider business mailing address

204 BETHEL ST
CLOVER SC
29710-1148
US

V. Phone/Fax

Practice location:
  • Phone: 980-834-9170
  • Fax:
Mailing address:
  • Phone: 843-901-4674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5024856
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: