Provider Demographics
NPI:1275562167
Name:CISSELL, AMY M (ARNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:CISSELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:BLACKWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 766351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1000 DUPONT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4611
Practice Address - Country:US
Practice Address - Phone:502-899-6405
Practice Address - Fax:502-889-6407
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5181P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3749683000OtherPASSPORT ADVTG - NHWM
KY2592936OtherCIGNA - NHWM
KY000000631045OtherANTHEM - NHWM
KY107785OtherSIHO - NHWM
IN200928570Medicaid
KY000051983YOtherHUMANA - NHWM
KY7100071580Medicaid
KYP00948795OtherRAILROAD MEDICARE - KY - NHWM
KY50026597OtherPASSPORT - NHWM
KY50026597OtherPASSPORT - NHWM