Provider Demographics
NPI:1164248449
Name:SORG, KISA SUE
Entity type:Individual
Prefix:
First Name:KISA
Middle Name:SUE
Last Name:SORG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S10904 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:SPRING GREEN
Mailing Address - State:WI
Mailing Address - Zip Code:53588-9738
Mailing Address - Country:US
Mailing Address - Phone:608-415-1524
Mailing Address - Fax:
Practice Address - Street 1:S10904 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:SPRING GREEN
Practice Address - State:WI
Practice Address - Zip Code:53588-9738
Practice Address - Country:US
Practice Address - Phone:608-415-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332331-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse