Provider Demographics
NPI:1508498015
Name:KRALLUM, JESSY (FNP-C)
Entity Type:Individual
Prefix:
First Name:JESSY
Middle Name:
Last Name:KRALLUM
Suffix:
Gender:M
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 1:6240 TACOMA MALL BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-6819
Mailing Address - Country:US
Mailing Address - Phone:253-271-9720
Mailing Address - Fax:720-598-0440
Practice Address - Street 1:6240 TACOMA MALL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-6819
Practice Address - Country:US
Practice Address - Phone:253-271-9720
Practice Address - Fax:720-598-0440
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202001367NP-PP363LF0000X
WAAP61044253363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily