Provider Demographics
NPI:1568057537
Name:PETERSON, KRISTIN TAYLOR (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:TAYLOR
Last Name:PETERSON
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 1:1114 DECATUR CONEHATTA RD
Mailing Address - Street 2:
Mailing Address - City:CONEHATTA
Mailing Address - State:MS
Mailing Address - Zip Code:39057-9408
Mailing Address - Country:US
Mailing Address - Phone:601-416-1729
Mailing Address - Fax:601-416-1729
Practice Address - Street 1:1314 19TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4116
Practice Address - Country:US
Practice Address - Phone:601-483-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904467363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily