Basic Information
| Provider Information | |||||||||
| NPI: | 1821628579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAZLETT | ||||||||
| OtherFirstName: | KRISTA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 128 WESTWICK CT | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371282502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157886239 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 641 E COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370912816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313594555 | ||||||||
| FaxNumber: | 9313590105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2020 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | 4185 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.