Basic Information
| Provider Information | |||||||||
| NPI: | 1265777460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSN,CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1704 GLENWOOD WAY | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454404080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376544642 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3095 KETTERING BLVD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938300 | ||||||||
| FaxNumber: | 9375341579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2012 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0807X | 348586 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Child & Adolescent | 364SP0807X | APRN.CNS.15040 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 0092420 | 05 | OH | MEDICAID |