Provider Demographics
NPI:1245296326
Name:SISCO, KRYN L (PMHNP-BC, MPA,BSN RN)
Entity type:Individual
Prefix:
First Name:KRYN
Middle Name:L
Last Name:SISCO
Suffix:
Gender:F
Credentials:PMHNP-BC, MPA,BSN RN
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:101 W TOWNSEND RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-9200
Mailing Address - Country:US
Mailing Address - Phone:989-403-6100
Mailing Address - Fax:989-403-6120
Practice Address - Street 1:812 E JOLLY RD
Practice Address - Street 2:STE 216
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-6818
Practice Address - Country:US
Practice Address - Phone:517-346-9554
Practice Address - Fax:517-346-8291
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704152662363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1245296326Medicaid