Provider Demographics
NPI:1285137380
Name:WALL, KAMIKA SHAREE
Entity type:Individual
Prefix:
First Name:KAMIKA
Middle Name:SHAREE
Last Name:WALL
Suffix:
Gender:F
Credentials:
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 515
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38088-0515
Mailing Address - Country:US
Mailing Address - Phone:901-484-9099
Mailing Address - Fax:470-222-2771
Practice Address - Street 1:7040 WIND STONE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-9090
Practice Address - Country:US
Practice Address - Phone:662-874-5828
Practice Address - Fax:662-874-5870
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN169468163W00000X
MS905658363LP2300X
MS916499163W00000X
TN24058363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care