Basic Information
Provider Information | |||||||||
NPI: | 1265032106 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HELTON | ||||||||
FirstName: | KRISTEN | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILSON | ||||||||
OtherFirstName: | KRISTEN | ||||||||
OtherMiddleName: | NICOLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 976 LC POPE RD | ||||||||
Address2: |   | ||||||||
City: | EAST DUBLIN | ||||||||
State: | GA | ||||||||
PostalCode: | 310271648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2293158649 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 654 COUNTY FARM RD | ||||||||
Address2: |   | ||||||||
City: | DUBLIN | ||||||||
State: | GA | ||||||||
PostalCode: | 310211799 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4782722051 | ||||||||
FaxNumber: | 4782756517 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2020 | ||||||||
LastUpdateDate: | 10/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN228241 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.