Provider Demographics
NPI:1417731548
Name:TRUSSELL, KRYSTAL CHANTAL (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:CHANTAL
Last Name:TRUSSELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8306 OKATIBBEE DAM RD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39325-8936
Mailing Address - Country:US
Mailing Address - Phone:601-616-4137
Mailing Address - Fax:
Practice Address - Street 1:8306 OKATIBBEE DAM RD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39325-8936
Practice Address - Country:US
Practice Address - Phone:601-616-4137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906203363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily