Provider Demographics
NPI:1326048562
Name:KISNER, AMY LYNETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:LYNETTE
Last Name:KISNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9375 BLUERIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-2661
Mailing Address - Country:US
Mailing Address - Phone:225-302-7187
Mailing Address - Fax:
Practice Address - Street 1:13702 COURSEY BLVD STE B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1370
Practice Address - Country:US
Practice Address - Phone:225-246-8000
Practice Address - Fax:225-246-8720
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19549208000000X, 207R00000X
LAMD.204734208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2165640Medicaid
P00009580OtherRAILROAD MEDICARE
WVG92288Medicare UPIN
P00009580OtherRAILROAD MEDICARE
P00009580Medicare PIN
LA4Q431C822Medicare PIN