Provider Demographics
NPI:1003390584
Name:KISER, ELLEN FERN
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:FERN
Last Name:KISER
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 1:9863 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:OH
Mailing Address - Zip Code:44288-1039
Mailing Address - Country:US
Mailing Address - Phone:330-307-7903
Mailing Address - Fax:330-543-3782
Practice Address - Street 1:9863 E CENTER ST
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:OH
Practice Address - Zip Code:44288-1039
Practice Address - Country:US
Practice Address - Phone:330-307-7903
Practice Address - Fax:330-543-3782
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH062500164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse