Basic Information
| Provider Information | |||||||||
| NPI: | 1902100654 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRISTIAN | ||||||||
| FirstName: | AVA | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3502 W NORTHSIDE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392134454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013625321 | ||||||||
| FaxNumber: | 6013645159 | ||||||||
| Practice Location | |||||||||
| Address1: | 3502 W NORTHSIDE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392134454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013625321 | ||||||||
| FaxNumber: | 6013645159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2011 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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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 | 363LF0000X | AP128767 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 06752203 | 05 | MS | MEDICAID |