Provider Demographics
NPI:1538401690
Name:KISNER, DIANNA (AT)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:
Last Name:KISNER
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4623 POINSETTIA AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-4505
Mailing Address - Country:US
Mailing Address - Phone:616-893-6918
Mailing Address - Fax:
Practice Address - Street 1:160 68TH ST SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-7114
Practice Address - Country:US
Practice Address - Phone:616-455-3210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL18904532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer