Provider Demographics
NPI:1902802440
Name:KISIEL, THERESA M (CRNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:KISIEL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E 2ND ST
Mailing Address - Street 2:STE 2
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1537
Mailing Address - Country:US
Mailing Address - Phone:817-456-8980
Mailing Address - Fax:814-451-0443
Practice Address - Street 1:120 E 2ND ST
Practice Address - Street 2:STE 2
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1537
Practice Address - Country:US
Practice Address - Phone:817-456-8980
Practice Address - Fax:814-451-0443
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAVP005796B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner