MEDICARE: MRS. KRISTINA STEWART LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	P326390	MS

General Provider Information

NPI Number	:	1124375118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTINA STEWART LPN

Provider Business Mailing Address
First Line	:	2012 W SECOND ST
Second Line	:	#159
City	:	LONG BEACH
State	:	MS
Zip	:	39560-5553
Country	:	US
Telephone Number	:	228-206-7200
Fax Number	:

Provider Business Practice Location Address
First Line	:	2012 W 2ND ST
Second Line	:	#159
City	:	LONG BEACH
State	:	MS
Zip	:	39560-5553
Country	:	US
Telephone Number	:	228-206-7200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2012
Last Update Date	:	08/08/2012

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