Provider Demographics
NPI:1124398367
Name:KISLAN, MICHELE MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MARIE
Last Name:KISLAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BUILDING 390, N LOOP ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310
Mailing Address - Country:US
Mailing Address - Phone:760-383-5289
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 390, N LOOP ROAD
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-383-5270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60563151183500000X
NC24986183500000X, 1835P0018X
WAPH605631511835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist