Provider Demographics
NPI:1861716532
Name:KISSIAR, CAROLYN D (CNP)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:D
Last Name:KISSIAR
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:D
Other - Last Name:MUELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:37 RUSTIC CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:ULLIN
Mailing Address - State:IL
Mailing Address - Zip Code:62992-2226
Mailing Address - Country:US
Mailing Address - Phone:618-634-2297
Mailing Address - Fax:618-634-9011
Practice Address - Street 1:37 RUSTIC CAMPUS DRIVE
Practice Address - Street 2:SOUTHERN SEVEN HEALTH DEPARTMENT
Practice Address - City:ULLIN
Practice Address - State:IL
Practice Address - Zip Code:62992-2226
Practice Address - Country:US
Practice Address - Phone:618-634-2297
Practice Address - Fax:618-634-9011
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041244469163W00000X
IL209001132207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No163W00000XNursing Service ProvidersRegistered Nurse