Provider Demographics
NPI:1730628199
Name:HISER, KARLY ROSE MCLEOD (DNP, RN, CPNP-PC)
Entity type:Individual
Prefix:
First Name:KARLY
Middle Name:ROSE MCLEOD
Last Name:HISER
Suffix:
Gender:F
Credentials:DNP, RN, CPNP-PC
Other - Prefix:
Other - First Name:KARLY
Other - Middle Name:ROSE
Other - Last Name:MCLEOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 BARCLAY AVE NE STE 300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2527
Practice Address - Country:US
Practice Address - Phone:616-391-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704324281363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics