Provider Demographics
NPI:1134678808
Name:KINZIE, YOLONDA
Entity Type:Individual
Prefix:
First Name:YOLONDA
Middle Name:
Last Name:KINZIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-2841
Mailing Address - Country:US
Mailing Address - Phone:601-984-5572
Mailing Address - Fax:
Practice Address - Street 1:1134 WINTER ST.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204
Practice Address - Country:US
Practice Address - Phone:601-984-5572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS866178163W00000X
MS9017774363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9427139431Medicare NSC