Basic Information
| Provider Information | |||||||||
| NPI: | 1003414509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | KATELYN | ||||||||
| MiddleName: | STALNAKER | ||||||||
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| Credential: | AGNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 LITTLE CIR | ||||||||
| Address2: | |||||||||
| City: | BELDEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388269118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624192105 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 499 GLOSTER CREEK VLG STE G1 | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388014751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623772663 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2020 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 897205 | MS | N | Nursing Service Providers | Registered Nurse | 363L00000X | 905648 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 897205 | 01 | MS | RN LICENSE | OTHER | 905648 | 01 | MS | APRN LICENSE | OTHER |