Basic Information
| Provider Information | |||||||||
| NPI: | 1568057537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | TAYLOR | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1114 DECATUR CONEHATTA RD | ||||||||
| Address2: | |||||||||
| City: | CONEHATTA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390579408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014161729 | ||||||||
| FaxNumber: | 6014161729 | ||||||||
| Practice Location | |||||||||
| Address1: | 1314 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014830011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2021 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 904467 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.