Basic Information
| Provider Information | |||||||||
| NPI: | 1124435094 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KISE | ||||||||
| FirstName: | SHAWN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636256 | ||||||||
| Address2: | CENTRAL CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132453104 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 PIEDMONT AVE | ||||||||
| Address2: | SUITE 4000 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452194231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2014 | ||||||||
| LastUpdateDate: | 06/23/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN.313227 | OH | N | Nursing Service Providers | Registered Nurse | 363LA2100X | COA.16198-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 0109068 | 05 | OH | MEDICAID |