Provider Demographics
NPI:1538627781
Name:BISSILA, HORTENSE
Entity type:Individual
Prefix:
First Name:HORTENSE
Middle Name:
Last Name:BISSILA
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 1:8225 ROCKCREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-4594
Mailing Address - Country:US
Mailing Address - Phone:901-800-1037
Mailing Address - Fax:877-669-2745
Practice Address - Street 1:4494 W PEORIA AVE STE 11-115A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-2023
Practice Address - Country:US
Practice Address - Phone:602-417-7670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR221247363LP0808X
TN25768363LP0808X
TX1150178363LP0808X
MS903306363LP0808X
AZ267709363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health