Healthcare Provider Details

I. General information

NPI: 1508498015
Provider Name (Legal Business Name): JESSY KRALLUM FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 04/09/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6240 TACOMA MALL BLVD STE 101
TACOMA WA
98409-6819
US

IV. Provider business mailing address

6240 TACOMA MALL BLVD STE 101
TACOMA WA
98409-6819
US

V. Phone/Fax

Practice location:
  • Phone: 253-271-9720
  • Fax: 720-598-0440
Mailing address:
  • Phone: 253-271-9720
  • Fax: 720-598-0440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61044253
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202001367NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: