Provider Demographics
NPI:1487639019
Name:HODGE, KRISTA K (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:K
Last Name:HODGE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:K
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-749-3714
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:6941 HIGHWAY 11 STE A
Practice Address - Street 2:
Practice Address - City:CARRIERE
Practice Address - State:MS
Practice Address - Zip Code:39426-7794
Practice Address - Country:US
Practice Address - Phone:601-749-3714
Practice Address - Fax:601-749-3776
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS767181363L00000X
MSR767181363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119083Medicaid
LA1568139Medicaid
LA1568139Medicaid
LA1568139Medicaid
MS5000000874Medicare PIN
MS364174YKFFMedicare PIN