Provider Demographics
NPI:1407858145
Name:MCKISSICK, NANCY J (NP-C)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:MCKISSICK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2366 E SHERRI DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3936
Mailing Address - Country:US
Mailing Address - Phone:260-413-8342
Mailing Address - Fax:
Practice Address - Street 1:500 N WEST SHORE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-5005
Practice Address - Country:US
Practice Address - Phone:855-893-2298
Practice Address - Fax:866-214-6824
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9467071363L00000X
AZAP2976363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100082060Medicaid
IN000000331132OtherBLUE CROSS BLUE SHIELD
IN200373280CMedicaid
FLJG949ZOtherMEDICARE
IN200373280CMedicaid
INP68017Medicare UPIN
IN500029116Medicare ID - Type UnspecifiedRR