Provider Demographics
NPI:1275380628
Name:WALL, KRISTINE (NP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 104780
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1511 CHRISTY DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-2854
Practice Address - Country:US
Practice Address - Phone:573-632-2777
Practice Address - Fax:573-632-2769
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024015564363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily