Provider Demographics
NPI:1033494919
Name:GISSONNE, KATHERINE SUSAN (RT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:SUSAN
Last Name:GISSONNE
Suffix:
Gender:F
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:200 W HOSPITAL DR --SR 73
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-3771
Mailing Address - Fax:928-338-3751
Practice Address - Street 1:200 W HOSPITAL DR
Practice Address - Street 2:SR 73
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-0860
Practice Address - Country:US
Practice Address - Phone:928-338-3771
Practice Address - Fax:928-338-3751
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN127380247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist