Provider Demographics
NPI:1467418392
Name:KIESSEL, CHRISTA (MSN, RN, CS, AOCNP)
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:
Last Name:KIESSEL
Suffix:
Gender:F
Credentials:MSN, RN, CS, AOCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5325
Mailing Address - Country:US
Mailing Address - Phone:231-935-6080
Mailing Address - Fax:231-935-6081
Practice Address - Street 1:217 S MADISON STREET
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2320
Practice Address - Country:US
Practice Address - Phone:231-392-8400
Practice Address - Fax:231-935-7888
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704192243363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4952443Medicaid
MI4952443Medicaid