Basic Information
Provider Information | |||||||||
NPI: | 1275562167 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CISSELL | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BLACKWELL | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | M. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 766351 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606776351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025889490 | ||||||||
FaxNumber: | 5022725116 | ||||||||
Practice Location | |||||||||
Address1: | 1000 DUPONT RD | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402074611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5028996405 | ||||||||
FaxNumber: | 5028896407 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2006 | ||||||||
LastUpdateDate: | 10/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5181P | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 3749683000 | 01 | KY | PASSPORT ADVTG - NHWM | OTHER | 2592936 | 01 | KY | CIGNA - NHWM | OTHER | 000000631045 | 01 | KY | ANTHEM - NHWM | OTHER | 107785 | 01 | KY | SIHO - NHWM | OTHER | 200928570 | 05 | IN |   | MEDICAID | 000051983Y | 01 | KY | HUMANA - NHWM | OTHER | 7100071580 | 05 | KY |   | MEDICAID | P00948795 | 01 | KY | RAILROAD MEDICARE - KY - NHWM | OTHER | 50026597 | 01 | KY | PASSPORT - NHWM | OTHER |