Provider Demographics
NPI:1477546117
Name:KISSANE, KATHLEEN M (RN, CRNP, MSN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:KISSANE
Suffix:
Gender:F
Credentials:RN, CRNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277045
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7045
Mailing Address - Country:US
Mailing Address - Phone:240-566-3330
Mailing Address - Fax:240-566-3892
Practice Address - Street 1:5500 BUCKEYSTOWN PIKE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8331
Practice Address - Country:US
Practice Address - Phone:240-379-6045
Practice Address - Fax:240-379-6050
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR089131163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
1257868OtherAETNA PVN
MD2221-0247OtherCERT. DIABETES ED.