MEDICARE: KERRY LANCE HESSELRODE NURSE PRACTITIONER

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	363LA2100X	Acute Care Nurse Practitioner	16127	CA
2	363LA2100X	Acute Care Nurse Practitioner	R770242	MS

General Provider Information

NPI Number	:	1518161322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY LANCE HESSELRODE NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	9321 LIVE OAK AVE
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-8530
Country	:	US
Telephone Number	:	228-217-4977
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 BEAUVOIR RD STE 5
Second Line	:
City	:	BILOXI
State	:	MS
Zip	:	39531-4026
Country	:	US
Telephone Number	:	228-388-2599
Fax Number	:

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

Provider Enumeration Date	:	06/14/2007
Last Update Date	:	08/21/2007

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