Provider Demographics
NPI:1518161322
Name:HESSELRODE, KERRY LANCE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LANCE
Last Name:HESSELRODE
Suffix:
Gender:M
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 1:9321 LIVE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8530
Mailing Address - Country:US
Mailing Address - Phone:228-217-4977
Mailing Address - Fax:
Practice Address - Street 1:250 BEAUVOIR RD STE 5
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4026
Practice Address - Country:US
Practice Address - Phone:228-388-2599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16127363LA2100X
MSR770242363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care