Basic Information
| Provider Information | |||||||||
| NPI: | 1790240174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | KRUTI | ||||||||
| MiddleName: | PRAKASH | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2153 DEPT 1947 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352870002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019925532 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1225 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016641300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2019 | ||||||||
| LastUpdateDate: | 04/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 903021 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.