Provider Demographics
NPI:1730414962
Name:KISER, SHANNON C (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:C
Last Name:KISER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 HOSPITAL DR
Mailing Address - Street 2:CORNWELL CENTER
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-2302
Mailing Address - Country:US
Mailing Address - Phone:740-566-4890
Mailing Address - Fax:740-566-4891
Practice Address - Street 1:65 HOSPITAL DR
Practice Address - Street 2:CORNWELL CENTER
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2302
Practice Address - Country:US
Practice Address - Phone:740-566-4890
Practice Address - Fax:740-566-4891
Is Sole Proprietor?:No
Enumeration Date:2009-10-06
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10947-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3014017Medicaid
OH3014017Medicaid