Provider Demographics
NPI:1528678406
Name:PERRICONE, KIRSTEN (APRN)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:PERRICONE
Suffix:
Gender:F
Credentials:APRN
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 220
Mailing Address - Street 2:
Mailing Address - City:GRAPELAND
Mailing Address - State:TX
Mailing Address - Zip Code:75844-0220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9516 FM 1097 RD W STE 140
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77318-4976
Practice Address - Country:US
Practice Address - Phone:936-539-4004
Practice Address - Fax:936-224-4205
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX839693163W00000X
TX1021328363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty