Basic Information
| Provider Information | |||||||||
| NPI: | 1922257278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KISE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KISE | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060308021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794477 | ||||||||
| FaxNumber: | 8606791017 | ||||||||
| Practice Location | |||||||||
| Address1: | 306 COMMERCE DR | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | LOUISA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 412305063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066387400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2008 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1054593 | KY | N | Nursing Service Providers | Registered Nurse | 363L00000X | 5673P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 5673P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 008855 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 3005673 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100058130 | 05 | KY | MEDICAID |