Provider Demographics
NPI:1013578061
Name:MOUNGER, KRISTY SMITH (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:SMITH
Last Name:MOUNGER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-434-1488
Mailing Address - Fax:803-434-1537
Practice Address - Street 1:116 HOSPITAL SQ
Practice Address - Street 2:
Practice Address - City:BISHOPVILLE
Practice Address - State:SC
Practice Address - Zip Code:29010-7081
Practice Address - Country:US
Practice Address - Phone:803-484-9424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22838363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP6526Medicaid