=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528678406
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRSTEN PERRICONE APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2020
-----------------------------------------------------
Last Update Date | 12/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9516 FM 1097 RD W STE 140
-----------------------------------------------------
City | WILLIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77318-4976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-539-4004
-----------------------------------------------------
Fax | 936-224-4205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 220
-----------------------------------------------------
City | GRAPELAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75844-0220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1021328
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 839693
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------