Provider Demographics
NPI:1467931535
Name:TISH, KELSEY ANGELA
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANGELA
Last Name:TISH
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 1:155 N 35TH AVE W
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IA
Mailing Address - Zip Code:50208-8637
Mailing Address - Country:US
Mailing Address - Phone:641-417-8987
Mailing Address - Fax:
Practice Address - Street 1:300 N 4TH AVE E STE 200
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IA
Practice Address - Zip Code:50208-3122
Practice Address - Country:US
Practice Address - Phone:641-792-2112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA137236363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily