Provider Demographics
NPI:1053720342
Name:HILLIE, KRISTAL (FNP)
Entity type:Individual
Prefix:
First Name:KRISTAL
Middle Name:
Last Name:HILLIE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 TANYA WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-7214
Mailing Address - Country:US
Mailing Address - Phone:901-218-2804
Mailing Address - Fax:
Practice Address - Street 1:1520 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38174-0275
Practice Address - Country:US
Practice Address - Phone:901-276-2410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR876849363LF0000X
TN19105363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily