Provider Demographics
NPI:1205395688
Name:KISSACK, DIANDRA BRIGETTE
Entity Type:Individual
Prefix:
First Name:DIANDRA
Middle Name:BRIGETTE
Last Name:KISSACK
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 1:721 S HENRY RD
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:WA
Mailing Address - Zip Code:99016-9617
Mailing Address - Country:US
Mailing Address - Phone:509-953-2928
Mailing Address - Fax:
Practice Address - Street 1:721 N PINES RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-5225
Practice Address - Country:US
Practice Address - Phone:509-892-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist