Provider Demographics
NPI:1023319936
Name:KNIGHT, KISHA L (FNP-BC)
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:L
Last Name:KNIGHT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KISHA
Other - Middle Name:L
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-3700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:404 LILLIE BURNEY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-5505
Practice Address - Country:US
Practice Address - Phone:601-450-6500
Practice Address - Fax:601-450-6503
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR863895363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS12181296OtherCAQH ID NUMBER
MS9900628OtherAETNA
MS05401590Medicaid
MS05401590Medicaid