Provider Demographics
NPI:1730776485
Name:BALLARD, KRISTINA (RN)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 CHALET DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-9622
Mailing Address - Country:US
Mailing Address - Phone:662-417-4793
Mailing Address - Fax:
Practice Address - Street 1:1209 SUNSET DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4063
Practice Address - Country:US
Practice Address - Phone:662-294-0665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS860917163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse