Provider Demographics
NPI:1336635812
Name:PALMER, KECIA LASONIA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KECIA
Middle Name:LASONIA
Last Name:PALMER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 COLONY PARK DR
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-6372
Mailing Address - Country:US
Mailing Address - Phone:769-572-2646
Mailing Address - Fax:
Practice Address - Street 1:768 AVERY BLVD N
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5219
Practice Address - Country:US
Practice Address - Phone:601-487-6482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-08
Last Update Date:2018-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902423363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care